I/We hereby state that the above information is true and correct to the best of my/our knowledge. I/We authorize the above named practice to release any information acquired in the course of my treatment to my insurance company, employer, Physicians, institutions or third party payers as required for certain claims filed. My/Our signature also signifies my/our consent to medical treatment deemed necessary by the physician and/or the office staff acting under the physician's direction. There are Physician Assistants/Nurse Practitioners that work with Dr. Lano who have extensive training and experience in the evaluation & treatment of Ear, Nose and Throat patients. They have experience in caring for surgical patients. They are supervised by Dr. Lano and may be involved in your care. Hill Country Ear, Nose & Throat provides some imaging services here in the office. If you wish to having imaging services provided at another location, we will provide you a list of local imaging services. Thank you.