Gastroenterology Center of Northern Virginia

HIPAA NOTICE OF PRIVACY

Gastroenterology Center of Northern Virginia

Permission Signature Document

hereby give myconsent to Gastroenterology Center of Northern

Virginia to use or disclose, for the purpose of carrying out treatment, payment, or health care operations, all information contained in the patient record of

I acknowledge the review and/or receipt of the physician's Notice of Privacy Practices. The Notice provides detailed information about how the practice may use and disclose my confidential information. I understand that GCOFNOVA has reserved the right to change its privacy practices, and that a copy of any revised Notice will be available to me upon written request.

I also authorize the physicians and staff of Gastroenterology Center of Northern Virginia to:

1. I do not want messages left for me. (please check here)

2. Leave a detailed message with the type oftest(s) performed. test results and/or any other comments related to my health at:

HIPAA INFORMATION RELEASE

1. Release any and all information pertaining to my health care, test results, procedures, billing, and/or accounting information to the following person(s) or agencies:

Name:

Relationship:

Name:

Relationship:

Name:

Relationship:

understand that this consent will be actively enforced and any

changes to this HIP AA release must be done in writing.

Patient's Name:

Signature

Date

About us

We would like to welcome you to the Gastroenterology Center of Northern Virginia, Ltd. We appreciate the opportunity to participate in your care. It is our sincere desire to provide you with the highest quality and most comprehensive services in the diagnosis, treatment and management of various digestive conditions.

HIPAA NOTICE OF PRIVACY