Patient's Name:
Chart Number:
Social Security Number:

Any physician, staff, employee or representative of Brookwood ENT Associates, P.C. has my permission to discuss my account and medical conditions which may include symptoms, treatments, diagnosis, test results, medications or any other type of protected health information with the following persons in order to facilitate and coordinate my care, treatment and payment:

Name:   Relationship:   Phone #:
Name:   Relationship:   Phone #:
Name:   Relationship:   Phone #:
Name:   Relationship:   Phone #:
Name:   Relationship:   Phone #:

I understand that authorizing the release of my information to the above individual(s) is voluntary and does not affect my access to treatment. I can refuse to sign this form. I can invoke it by writing to Brookwood ENT Associates, P.C. or by completing a new form at any time. This authorization will remain in effect until I change or revoke it. I understand that if information is shared with the above individuals it may be subject to redisclosure by the individual(s).

Patient Signature:   Date:
(If Patient is a child, Parent or Guardian):
Relationship to Patient: