- As part of my care, ENTOffice.org creates and keeps my health record. This record includes my health history, why I am being seen as a patient at ENTOffice.org, what I talk about with the doctor, nurse, or medical assistant, any tests I have done, and what the doctor plans for my treatment.
- am giving permission for my insurance company to pay ENTOffice.org for any surgical and/or medical benefits available to me under my current insurance plan.
- know that (unless I am covered by Medicaid) I am responsible for the part of my bill insurance does not cover.
- Due to individual policies and plans, treatment may be subject to deductible and/or coinsurance. By signing this agreement, I acknowledge I am responsible for these charges.
- have certain rights to privacy about my health information. This is because of the Health Insurance Portability and Accountability Act (HIPAA) of 1996. I understand that by signing this form I give permission for ENTOffice.org to use and share my protected health information to do the following:
o Treatment (the action, medicine, or therapy) ordered by the doctor
o Talk with other doctors or people responsible for my care
o Getting payment from my insurance company
o Showing my insurance company what the doctor did at my visit
o Making sure ENTOffice.org can measure the ability and effectiveness of the doctors, nurses, and medical assistants.
- ENTOffice.org has the right to change the terms of this notice from time to time and that I may contact you at any time to get the most current (up to date) copy of this form and the Notice of Privacy Policies.
- have the right to ask for changes to (or limitations on) how my protected health information is used and shared in order to treat me, collect payment, and carry out other health care actions. ENTOffice.org is NOT required to agree to the changes I ask for. However, if ENTOffice.org does agree, it must follow the changes I ask for.
I have also been informed of and given the right to review and secure a copy of the Notice of Privacy Policies, which:
- Has a better description of the uses and sharing of my protected health information,
- Talks about my rights under HIPAA.
I understand that I may cancel or take back this permission, in writing, at any time. However, any use or sharing of my information that happened before I take back permission is not changed.
DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this