Gastrointestinal Endoscopy Associates, LLC, complies with these standards. As a general principle, we will always assume that you have instructed us NOT to release your medical records, or any portion thereof, to anyone, except under the usual, general circumstances covered, below.

Please read and sign this GENERAL AUTHORIZATION CONCERNING YOUR MEDICAL RECORDS.

Relevant portions of my medical record may be provided to:

1. other designated doctors and their staffs (e.g., this practice; primary or referring doctors and their staffs; hospital or out-patient facilities, endoscopy unit, or surgical-day-care).
2. my medical insurance company to document specific services) provided and billed.
3. the Government, as required by law (e.g., subpoena).
4. the family member/or person accompanying me today (name)__________________________________.

If you wish to have a detailed enumeration of all of the specifics and rights summarized above, now or at any time in the future, please initial "yes", below; let our staff know; and the relevant forms will be provided:

If you wish to designate (a) person(s) (other than those above) to be given access to all or part of your medical record, or if you wish to revoke such designation, please initial "yes" below; let our staff know; and the relevant forms will be provided:

Please specify by checking the appropriate answer below, if we may leave health-related information (e.g., lab/biopsy/x-ray results, billing issues, or other doctor-patient communications) on your:

Home answering machine _____________Yes _____________No

Work voicemail _____________Yes _____________No

(Please note that if the above section is not completed, we will assume that we have your approval to contact you using any one of these methods.)

I acknowledge that I have read, understand, and agree to the above.

GIEA
Gastrointestinal Endoscopy Associates, LLC
15005 Shady Grove Road, Suite 200
Rockville, MD 20850
Tel: 301.340.8099
Fax: 301.340.8535
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