Authorization to Consent: (Adult Patient)

I, am giving consent for the below mentioned person/persons to obtain medical care for myself in my absence. I understand I am fully responsible for all medical expenses incurred with said medical treatments.

Authorization to Consent: (Pediatric Patient)

I, am the parent of and/or legal guardian for the above mentioned patient and am giving consent for the below mentioned person/persons to obtain medical care for this patient in my absence. I understand that I am fully responsible for all medical expenses incurred with said medical treatments.

Access to All Medical Records
Financial Records Only
Designated Representative
Relationship to Patient



• All Medical Records would include making appointments, picking up prescriptions, release of records, etc.

• By signing, I acknowledge that I have read and received a copy of the Oklahoma Otolaryngology Associate, LLC’s and/or Oklahoma Hearing Center’s Notice of Privacy Practice/Patient Rights and Responsibilities, as required by HIPAA.

• By signing, I acknowledge that I have read and received a copy of the Oklahoma Otolaryngology Associate LLC’s and/or Oklahoma Hearing Center’s Financial Policy.

• By signing, I acknowledge that I have read and received a copy of the Oklahoma Otolaryngology Associate LLC’s and/or Oklahoma Hearing Center’s Ownership Disclosure Policy.

• I understand that if I want to make any changes to the information listed above, I must contact Oklahoma Otolaryngology Associates and/or Oklahoma Hearing Center to revoke this form in its entirety or complete a new form.

Signature of Patient
Witnessed
Signature of Parent/Legal Guardian
Relationship to Patient

In Case of Emergency, I can be reached at: (Emergency phone)

I, do not wish to allow anyone other than myself to have access to my medical records and/or financial records for any reason.