Skip to content
(423) 267-5677
info@goodman-gi.com
Mon - Fri: 9:00 - 5:00
Search
Our Providers
Dr. Michael Goodman
Caitlin Grant Collier, FNP
Treatment Info
Common GI Diseases and Disorders
Preps and Procedures
Understanding Colonoscopies
Infliximab Treatment for Crohn’s & Colitis
In-Office Endoscopy Suite
Patient Forms
Patient Bill of Rights
Patient Packet
Patient Satisfaction Survey
FAQs
General FAQ
Billing FAQ
Our Providers
Dr. Michael Goodman
Caitlin Grant Collier, FNP
Treatment Info
Common GI Diseases and Disorders
Preps and Procedures
Understanding Colonoscopies
Infliximab Treatment for Crohn’s & Colitis
In-Office Endoscopy Suite
Patient Forms
Patient Bill of Rights
Patient Packet
Patient Satisfaction Survey
FAQs
General FAQ
Billing FAQ
Authorization For Use and Disclosure of
Protected Health Information
Patient Name
Information to Be Used or Disclosed
The information covered by this authorization includes:
All medical records
Office notes
Inpatient records
Discharge Summary
Reports of tests and xrays
Outpatient records
Face Sheets with Final Diagnosis
Emergency room records
Abstracts
Procedures and Complications
Consultation reports
Physical therapy
History & Physical Records
Outpatient clinic notes
Other
Other
Purposes of Disclosure
Information listed above will be disclosed for the following purposes:
For my doctor’s information
For designated persons information
Other
Other
Persons Authorized to Use or Disclose Information
Information listed above will be used or disclosed by:
MICHAEL W. GOODMAN, M.D.
Persons to Whom Information May Be Disclosed
Information described above may be disclosed to:
Spouse
Son/Daughter
Friend
Doctor
Other Relationship
Date of Authorization
From
Through
Right to Terminate or Revoke Authorization
This authorization may be revoked at any time by submitting a written revocation to MICHAEL W. GOODMAN, MD, P.C., 979 E. Third Street, Suite C-0630, Chattanooga, TN 37403. You should contact the Privacy Officer to terminate this authorization.
Patient or Representative
Rationale for serving as Patient Representative (if applicable)
Date Accepted
Patient Date of Birth
Patient Social Security Number
Send
We use cookies to improve your experience on our site.
I understand and accept the use of cookies.
