To help reduce additional administrative work on your end, Precision’s legal department has prepared a Report Signature Authorization Form.
Please review, sign, and date the form.
This form grants Precision and MDR staff pre-authorization to make clerical edits to your reports without needing to contact you for each change.
Clerical edits include corrections to spelling, punctuation, grammar, dates of birth, missing intake information, and similar non-medical details.
As always, any potential edits involving medical content or impressions will be emailed to you individually for review. No medical edits will be made without your written authorization.
If you have any questions, please refer back to management.
Report Signature Authorization Form
In the course of my professional role with Precision Occupational Medical Group, Inc. (“Precision”) and its management company MDR Network Care, LLC (“MDR”), I generate “EMG/NCV” reports and Electrodiagnostic
Medicine Consultation reports (“Consultation Reports”) (collectively, the “Reports”). These Reports are produced as part of the care of patients receiving treatment and diagnostic testing or evaluation by myself and other doctors or staff at Precision.
In the case of an EMG/NCV report, I create a draft report based on my examination, the raw data gathered in the
study, and the patient demographic information. I hereby authorize and direct MDR staff to review my draft reports and supplement and correct such reports as needed to ensure each accurately reflects the information provided by
the patient and the examination I performed, and if missing, affix my signature; MDR Staff is not authorized to make other changes without my express written/email approval, including without limitation changes to medical data,
findings and impressions.
In the case of Consultation Reports, I hereby authorize MDR staff to create draft Consultation Reports based on my EMG/NCV reports, the raw data noted during my examination and testing, as well as information from the patient’s file. MDR staff shall ensure that the substance of the examination, testing, patient file and medical records are accurately reflected in each such draft Report. I understand that MDR staff will provide draft Consultation Reports to me via secure email for my review, and that I have three business days thereafter to review such draft Reports and contact MDR staff with any corrections or my approval. If I do not contact MDR staff in three business days to either approve or correct the report, or request additional review time, MDR staff may assume that I have reviewed and approved the draft Report. Upon the conclusion of such time period, I understand that the draft Report will be
deemed final, my signature will be affixed to the Report, and it will submitted to the patient’s treating physician and elsewhere as appropriate.
Limitations on Authorization
This Authorization does not allow or apply to the use of my electronic signature on Reports for patients that I have not personally examined or tested. This Authorization does not allow MDR staff to modify a Report without my prior permission, other than set forth above. This Authorization does not apply to any documents other than the Reports mentioned specifically above; should Precision or MDR desire to use my signature on any other documents or reports, my express permission must be obtained prior to doing so. This Authorization supersedes any prior signature authorizations, which are void upon my signature below.
Subject to the limitations set forth herein, I agree with the foregoing use of my electronic signature. I may revise or
revoke this authorization at any time by providing written notification to Precision. This authorization expires upon the termination of my relationship with Precision as evidenced by all Reports from my work being finalized and
submitted for billing.
Confirmation
I also hereby certify that the information provided in this form is true, accurate, and complete to the best of my knowledge and belief. I understand that providing false, misleading, or incomplete information may result in denial of my application or other legal consequences.
