I have received a copy of The ENT Center's Notice of Privacy Practices
Please use the section below if you are signing on behalf of a minor or as a legal guardian
I grant permission for The ENT Center to discuss/release medical and billing information to the to the following following person(s):
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.