Patient Signature On File

FINDLAY EAR NOSE & THROAT ASSOC., INC.

1110 WEST MAIN CROSS STREET FINDLAY, OHIO 45840

(419) 424-1393

SIGNATURE ON FILE

I authorize release of information to all my Insurance Companies.

I authorize payment direct to my doctor.

I understand that I am responsible for the balance of my services not covered by insurance.

I authorize and request Findlay Ear Nose & Throat release information back to my referring/familydoctor/school.

I have received the Practice's Notice of Privacy Practices and understand that my protected health information may be used by the Practice as described in the notice.

I authorize treatment, such as a CT scan or other testing to be performed here at Findlay Ear Nose & Throat if my doctor and I agree that it is necessary for my healthcare.

Can we leave a message on an answering machine/voicemail/email regarding your healthcare?:
YesNo

Phone Number:

E-mail address:

Who do you authorize Findlay Ear Nose & Throat to release information to regarding your healthcare? (if left blank we will assume that we cannot release to anyone but the patient or legal guardian):

Patient Name :

Signature (patient or gaudian):

Date:

Select Date