Fayetteville Gastroenterology Associates, P.A

Consent

I have read Fayetteville Gastroenterology Associates, P.A. Notice of Privacy Practices and understand that as a patient I have the right to limit the use and disclosure of my personal health information (PHI).

I authorize Fayetteville Gastroenterology Associates, P.A. to realease my PHI to another healthcare provider for treatment or payment of my healthcare needs. I understand that should a third party request my PHI I will be required to come into the office and sign an authorization for Fayetteville Gastroenterology Associates, P.A. authorizing the realease of my PHI.

I authorize Fayetteville Gastroenterology Associates, P.A. to leave messages at my home or other designated telephone numbers confirming appointments with the physicians of Fayetteville Gastroenterology Associates, P.A. I also consent to the clinical staff leaving a message dealing with negative laboratory test results.

I hereby authorize Fayetteville Gastroenterology Associates, P.A. to discuss my PHI with the following family members or entrusted personnel:

NAME                    RELATIONSHIP             TELEPHONE

_________________       _________________        _________________

_________________       _________________        _________________

_________________       _________________        _________________

_________I do not give consent for any of my personal healthcare information being disclosed with anyone other than myself. I do give consent for my personal healthcare information being disclosed to another healthcare provider for treatment or payment of my healthcare needs.

This request is effective as of today and will not expire until December 31, 2025. I understand that I may revoke this consent at anytime by submitting a written request.

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Patient signature                  Date

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Legal Guardian                     Date

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Witness Signature                  Date