I Understand That:
■ I can revoke all or part of this authorization at any time by notifying Waterville Audiology in writing.
■ I can refuse to disclose all or some of my treatment records
■ Our office routinely makes reminder telephone calls to confirm appointments. If we reach an answering machine, we will leave a message with our practice name and the time and date of your appointment. If you do NOT want us to leave
you a message, please contact the front desk.
■ A refusal or revocation to release some or all information may result in improper diagnosis or treatment, denial of insurance coverage or a claim for health benefits, or other adverse consequences.
■ I can have a copy of this form upon request.