I certify that the above information is correct. I consent to be treated by the staff and providers of, Southeastern Gastroenterology Associates, PC and its affiliates. I authorize payment of medical benefits to Southeastern Gastroenterology Associates, PC and its affiliates, and authorize them to release any medical information necessary to process claims. I understand that I am responsible for co-payments, deductibles, co-insurance, and non-covered services.
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.