I understand that my signature below gives Gastrointestinal Endoscopy Associates, LLC (GIEA) permission, to the extent necessary, to use my medical record, and to provide access to my medical record, while and after I am treated by GIEA, for all the reasons that follow:

1. For the purpose of providing treatment to me;
2. For the purpose of arranging for payment for my care;
3. For the purpose of other health care providers' "health care operations" to the extent that they have a relationship with me.
4. For the purpose of GIEA's "health care operations." This last category includes such things as internal quality assessment activities, contacting other health care providers regarding treatment alternatives, evaluating provider performance, training providers of care, legal and medical review of care provided, business planning and management, customer service, resolution of internal grievances and the provision of legal and auditing services.

I understand that my permission allows GIEA to transmit permissible information through any means that is reasonably secure, including via e-mail, assuming that reasonable protective measures are taken to preserve the confidentiality of the information.

I understand that I may revoke this authorization at any time, but that GIEA may refuse to give me further treatment if I do so.

I understand that I have the right to request that GIEA restricts how my medical information is used.

If I wish to request a restriction, my initial here will alert GIEA staff to give me a separate form to fill out, which will also be used for GIEA to indicate whether or not GIEA agrees to the requested, restriction. ______________(initials)

I understand that I have a number of rights identified below (and listed more fully on the Patient Notice provided to me by GIEA):

• The right to review, and copy, my medical record
• The right to request the amendment (changing) of my medical record
• The right to grant or deny access to my record to others
• The right to decide how information from my record will be conveyed to others
• The right to complain about how my records are handled, to the Secretary of the U.S. Department of Health and Hunan Services
• The right to revoke, in writing, any consent that I provide for access to my record
• The right to authorize GIEA to give information about my care to relatives or close friends, to the extent of their involvement with my care or payment
• The right to review a record of access to my medical record

I understand that I have the right to either grant or deny access to my medical record, and that my specific written permission will be sought if access is requested for any reason not set forth above, or, in most cases, for the release of psychotherapy notes.

Gastrointestinal Endoscopy Associates, LLC, (GIEA) may decide to change some of the above-stated policies, and I understand that I will be given a revised Notice if this occurs.

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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