Please sign this document and return to NFTP with specific instructions about your case and how you would like us to represent his case.
I, _____________________________, hereby give my limited power of attorney to the National Foundation for the Treatment of Pain, and to it’s representatives Retired Officer Thomas M. Greenly, National Coordinator; J.S. Hochman M.D., Executive Director. I am requesting that any and all medical information be released to these agents, be it written, electronic or via telephone, for the sole purpose of assisting me with my chronic intractable pain. It is further understood and requested that any information or documents be provided to them upon request.
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Patient: Date Time
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Spouse or Family Member: Date Time