Augusta Ear, Nose and Throat, PC
Patient Consent to the Use and Disclosure of Health Information For Treatment, Payment, or
I understand that as part of my health care, Augusta ENT, PC originates and maintains paper and/or electronic records describing my health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care or treatment. I understand and have been provided with a Notice of Privacy Policies that provides a complete description of information uses and disclosures in addition to my rights. I understand that Augusta ENT, PC is not required to agree to any restrictions requested by me. I understand that I may revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereon. I also understand that by refusing to sign this consent or revoking this consent, this organization may refuse to treat me as permitted by Section 164.506 of the Code of Federal Regulations. I further understand that Augusta ENT, PC reserves any right to change their notice in accordance with Section 164.520 of the Code of Federal Regulations. Should Augusta ENT, PC change their notice an updated copy will be available upon my next visit to the practice and/or I may request a copy be sent to my address. I also may visit the office at any time to obtain a current copy of the practice’s Notice.
I understand that as part of this organization’s treatment, payment, or health care operations, it may become necessary to disclose my protected health information to another entity, and I consent to such disclosure for these permitted uses, including disclosures via fax.
Augusta ENT, PC may call the number I have indicated, if applicable, and leave the appointment date and time on my telephone answering machine, voicemail, or with whomever answers my phone if I am not available. I understand that other individuals may have access to the information left by this method. I understand that no other information will be provided in granting permission to leave the date and time.
Augusta ENT, PC may email my home or other address I have indicated, if applicable, any information that will assist Augusta ENT with the treatment, payment, and health care operations
for the patient. This can include appointment reminders, statements, insurance information, and
any information concerning my clinical care.
Augusta ENT, PC may send a text message to my cellular phone, if applicable, regarding appointment reminders, cancellations, or time changes. This form of communication will be for the use of the Appointment Desk and not private or clinical information.
I fully understand and accept the terms of this consent.