HIPAA Privacy Policy Authorization Form

• The educational pamphlet entitled "Notice of Privacy Practices" provides information about how Gastro Center of Maryland may use and disclose protected health information about you and is compliant with the requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
• Our Notice of Privacy Practices states that we reserve the right to change the terms described. Should this happen, you will receive a revised copy either by mail or in person.
• You have the right to request restrictions on how your protected health information may be used or disclosed for treatment, payment, or health care operations. We are not required to agree to your restrictions, but if we do, we are bound by our agreement with you.
• As a self-pay patient you have the right to decline the disclosure of your health information to any insurance carrier.

I, hereby authorize Gastro Center of Maryland to release medical information to my referring physician, primary care doctor, case manager, and any other individual involved in my medical care for the sole purpose of facilitating my treatment. I understand that my medical information is confidential and that I have a choice to request that my physician not share my medical records with any of the above individuals. Should I choose to exercise this right, I will provide in writing to my physician any of the individuals involved in my care that I do not wish to receive my medical records. I agree that a copy of this release may be used in place of the original.

I am aware that I may request that this Release of Medical Information may be revoked at any time by providing the physician's office with a dated and signed letter. I have read and agree to those terms.

I authorize Gastro Center of Maryland and Cumbria Capital MSO, LLC and its officers, agents, affiliates, employees to communicate with me regarding my medical care, appointments, test results, billing, and other healthcare-related matters via phone, email, text message, and secure patient portal. I understand that these communications may include voicemail messages and electronic correspondence as necessary for my care. I acknowledge that while Gastro Center of Maryland and Cumbria Capital MSO, LLC and its officers, agents, affiliates, and employees take measures to protect my privacy, electronic communications may not be fully secure. This authorization will remain in effect until I provide written notice to revoke it, or until I am no longer a patient receiving teatment by Gastro Center of Maryland and its affiliates.

It is often difficult to reach a patient to discuss appointments, medications, and other information pertinent to our patients' care. In this event, with your signed authorization, we would discuss such information with the person you designate. Please complete the section below.

I hereby authorize Gastro Center of Maryland to discuss any information required during my examination or treatment (when I cannot be reached by phone) to the following designated person(s).

By signing below, you acknowledge receipt of our Notice of Privacy Practices. Treatment at the Gastro Center of Maryland and its affiliated Endoscopy Centers will only be provided upon signing this form.

Cascades Endoscopy Center & Olney Endoscopy Center & Annapolis Endoscopy Center & Riverdale Endoscopy Center Timonium Endoscopy Center