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Authorization for Release of Medical Information (PDF)
Autorización De HIPAA Para Divulgar Información Del Paciente (PDF)
Allows patients to authorize the disclosure of their health information to a designated individual, company, agency or facility.
Authorization and Consent for Treatment (PDF)
Autorización y Consentimiento Para el Tratamiento (PDF)
All patients must provide their consent for treatment, communications (calls, emails, and text messaging), and agreement of fi nancial responsibility.
Patient Designated Contacts (PDF)
Contactos designados del paciente (PDF)
Patients are encouraged to complete and return the Patient Designated Contacts Form but it is not required.
Informed Consent for Telehealth Services (PDF)
Consentimiento informado para servicios de telesalud (PDF)
This policy describes the process for the documentation, maintenance and transmission of information using virtual visit technology.
Health Information Exchange (HIE) Opt-Out (PDF)
Formulario de solicitud de exclusión voluntaria de Privia HIE (PDF)
This form allows patients to opt out of sharing their PHI via the Health Information Exchange (HIE). The HIE securely shares patient information electronically among a network of healthcare providers, such as physicians, hospitals, labs and pharmacies.
Consent for Medical Treatment of Minor Children
In absence of parent(s) or legal guardian
Financial Policy (PDF)
Política Financiera (PDF)
This form advises patients of their complete financial responsibility for all medical services received without regard to insurance eligibility or coverage determinations.
Notice of Privacy Practices
Aviso de prácticas de privacidad
Describes how health information about you (as a patient of Maryland ENT Associates) may be used and disclosed, and how you can get access to your individually identifiable health information. Please review this notice carefully.
Notice of Nondiscrimination
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