In an effort to protect each person’s privacy, C Rodney Susong, MD PC and their staff are NOT allowed to give information on any patient, whether by phone or in person, without the written permission from the patient. We will NOT allow a person other than yourself to pick up medical records, test results, disability forms, prescriptions, etc., unless prior written consent is obtained from you the patient or responsible party.

Please specify the people you are giving written permission for:

I acknowledge receiving/being offered today a copy of the Provider’s Notice of Privacy Policies. I may pick up a copy at the front desk. By signing below, I am authorizing the practice to disclose my protected health information to the person’s I have listed above or to other health care providers involved in my medical treatment. I understand my rights and how to revoke this permission as described in the Notice of Privacy Practices offered to me by the practice.