SGI Established Patient Paperwork

Southeastern Gastroenterology Established Patient Paperwork
Please read and review the document below before completing and signing this form.
I authorize Southeastern Gastroenterology Associates in regards to my protected health information:

To speak with anyone listed on the Right to Share Information list, and to give my prescriptions to them as indicated below. To speak only with me.
Right to Share Information with Family and Friends

Southeastern Gastroenterology Associates reserves the right to communicate PHI with family or friends when it is deemed in the best interest of the patient as described in the Notice of HIPAA Policies.

In order to have your PHI shared in other circumstances with members of your family or friends, please list the individuals that we are authorized to release information to.

Family and/or Friends:

	Name	Yes, can pick up prescriptions	No, cannot pick up prescriptions
Name
Name
Name
Name

Southeastern Gastroenterology Established Patient Paperwork