I hereby authorize Hill Country Ear, Nose & Throat, and affiliated or other providers to release any information acquired during my treatment to my Insurance company, employer, or third-party payer as allowed under the Treatment, Payment, and Operations exceptions under HIPAA.

I understand that the specific information to be released may include, but is not limited to, the history of diagnosis and/or treatment of all related illnesses including HIV virus and Acquired Immune Deficiency Syndrome (AIDS).

I authorize direct payment to be made to Hill Country Ear, Nose & Throat, or other providers for any all medical or surgical services rendered. I understand that if any services or charges are not covered, or if Hill Country Ear, Nose & Throat is unable to verify eligibility, that I am responsible for all charges incurred for services rendered.

I understand that my doctor is an attending physician at hospitals that may be out of network with my insurance plan. I understand that I have the option to get my care at either an in network or an out of network facility and that if I have any questions regarding this, I can ask my doctor or the business office for further information.

I understand I have the right to communicate advance directives to my provider and provide copies of these directives to be placed in the medical record.

I understand during some office visits; it may be recommended that the provider use an endoscope to further evaluate a condition. This is a separate procedure from the office visit. This procedure will create an additional charge.

I hereby voluntarily consent to such healthcare encompassing diagnostic procedures and treatment by my physicians, and my physician's associates, assistants, and healthcare providers, as may be necessary in my physician's judgement. I have relied on my physicians for information in this regard and acknowledge that no warranty or guarantee has been made to me as to result or cure.

This form has been fully explained to me, and I certify that I understand its contents.

I have reviewed this Office's Notice of Privacy Practices, which explains how my medical information will be used and disclosed. I understand that I am entitled to receive a copy of this document.

I understand that Hill Country Ear, Nose & Throat requires at least 24-hour notice of appointment cancellation for office visits. Office appointments missed and not previously cancelled or rescheduled 24 hours prior to the appointment may be charged a fee of up to $50.00. Allergy Testing must be cancelled or rescheduled at least 48 hours in advance of the appointment, or the patient may be charged a missed appointment fee of $150. Appointments for In-Office Procedures or Surgery must be cancelled or rescheduled at least 48 hours in advance of the appointment, or the patient may be charged a missed appointment fee of $250.

Signature on this form hereby represents the signed consent from the patient's legal guardian/guarantor, unless the minor can affirmatively provide documentation of legal emancipation.