Consent to Treat

Consent to Treat

I voluntarily authorize and consent to the medical care, treatment, and diagnostic tests that the physicians at Texas Modern Gastroenterology and their designated associates or assistants believe are necessary. I also consent to the taking of photographs or films related to the care and treatment of the patient and understand that such photographs or films may be made part of the medical record. I understand that by signing this form, I am giving permission to the doctors, nurses, physician assistants, nurse practitioners, and other health care providers in this medical office to provide treatment as long as a physician/patient relationship exists, or until I withdraw my consent.

Sharing Records for Treatment

We share medical records with other health care providers to allow and promote continuity of care among providers. If you visit another provider, they may have access to your medical record.

Acknowledgment of Financial Policy

I acknowledge receiving Texas Modern Gastroenterology's Financial Policy. This Policy explains my financial responsibility and how any past due balances will be handled. A copy may be obtained through the front desk, if you should have questions please contact our Billing Manager at (903)558-2222.

Acknowledgment: Notice of Privacy Practices

I acknowledge receiving Texas Modern Gastroenterology's Notice of Privacy Practices ("Notice"). The Notice explains how Texas Modern Gastroenterology may use and disclose the patient's protected health information (PHI) for treatment, payment and health care operations purpose. "Protect health information" means that patient's personal health information found in the patient's medical and billing records. If you have questions about the Notice, please contact the Office Manager at (903)558-2222.

Acknowledgment of Office Information & Policies

I acknowledge receiving Texas Modern Gastroenterology's Office Information & Policies. By acknowledging this, I am accepting the policies stated. I have read this form or this form has been read to me in a language that I understand, and I have had an opportunity to ask questions about it.