Nancy B. Stroud, M.D. Amanda Naramore, WHNP

Elizabeth Dacus, M.D. Elizabeth MacNaughton, WHNP

Nancy B. Stroud, M.D. Amanda Naramore, WHNP

Amy Miller, M.D. Catherine Crosby, FNP

AUTHORIZATION

I, (patient) ______, give permission for the following people to receive any confidential information regarding myself from the office of Nancy Stroud, M.D.; Amy Miller, M.D.; Elizabeth Dacus, M.D.; Amanda Naramore, WHNP.; Elizabeth MacNaughton and Catherine Crosby WHNP

______Relationship: ______

______Relationship: ______

______Relationship: ______

______

Patient’s Signature Date

Test results may or may not (circle one) be left on my answering machine/voice mail

LABCORP

We send all lab work to LABCORP. If your insurance is not accepted at this facility, it is your responsibility to let us know. We cannot be responsible for lab bills that are denied by your insurance.

All Pap Smears, biopsies, blood work, cultures, etc. will be done by LABCORP. If you have any questions, please see a member of the nursing staff.

_____ You may send my labs to LABCORP

_____ Other instructions: ______

Signature: ______Date:______

Acknowledgement of Receipt of Notice of Privacy Practices

(To be filed in patient’s medical record)

I have been presented with a copy of the Notice of Privacy Practices, detailing how my health information may be used and disclosed as permitted under federal and state law, and outlining my rights regarding my health information.

Signed:______Date:______

Relationship (if not signed by patient): ______

9279-A Medical Plaza Drive • North Charleston, SC 29406 • Phone: (843) 569-2900 • Fax: (843) 569-7752

www.seasonsobgyn-sc.com