Patient Acknowledgement Form

Acknowledgement

I have received a copy of The ENT Center's Notice of Privacy Practices

Parent / Legal Guardian

Please use the section below if you are signing on behalf of a minor or as a legal guardian

Patient Authorization for Use and Disclosure of Protected Health Information
Authorized Person(s)

I grant permission for The ENT Center to discuss/release medical and billing information to the to the following following person(s):

Patient Signature

HIPAA (Health Insurance Portability Accountability Act) privacy rules give you the right to request a restriction of your protected health information (PHI). When PHI is used or disclosed pursuant to this authorization, it may be subject to re-disclosure by the recipient and may no longer be protected by the federal HIPAA privacy rule.

On behalf of Minor or Legal Guardian

Please use the section below if you are signing on behalf of a minor or as a legal guardian

submitting