North Texas Diabetes & Endocrinology, P.A.
4101 Kirkpatrick Lane, 
Flower Mound, TX 75028
2145132300   Fax: 2145132333

Consent to Treat
The undersigned consents to any examination or medical treatment, and or services rendered to the patient by 
Providers at NTDE and staff, during the course of diagnosis and treatment.  It is understood that the practice of medicine is not an exact science, and no guarantee can be given by anyone as to the results that will be attained from any diagnosis or treatment.  I have been given a copy of the office policies.  I have read and understand these policies.

Signature: ____________________________________          Date: _____________________

Patient Authorization for Contact
I authorize North Texas Diabetes & Endocrinology P.A. to contact me and leave messages regarding my protected health information, (including but not limited to; appointment reminder calls, test results, etc.) at these numbers.
***Please check appropriate boxes; if possible please list at least 2 contact numbers***

q Home #____________________    q Cell #____________________

q Work #____________________

q OPTIONAL 
If I am not available, you may release my protected health information to the following person(s):

________________________________     Phone #__________________       ___________ Relationship to patient

________________________________     Phone #__________________        ___________ Relationship to patient

Authorization for the Release of Information and/or Medical Records
I consent and authorize North Texas Diabetes & Endocrinology P.A (NTDE) to release protected health information contained in any financial or medical records, including but not limited to: diagnosis and treatment, information concerning communicable disease, drug or alcohol abuse, psychiatric diagnosis and treatment, medical history, lab results, progress notes, and other related information to insurance companies and its agents, Medicare and Medicaid, or any other entity responsible for paying or processing payment, utilization management, or consulting and/or follow up care and other healthcare operations. North Texas Diabetes and Endocrinology P.A. is hereby authorized to release any information or records and reports regarding patient care and health status as required by law or regulation.  Information may be transmitted by mail, facsimile, or other electronic medium. 

I have had an opportunity to read the Notice of Privacy Practices before I signed this consent. I understand that NTDE has the right to make changes to its privacy practices and issue a revised Notice of Privacy Practices. I understand that I may revoke this authorization in writing at any time, except to the extent that action is already in progress. The undersigned certifies that he or she has read, understands, and accepts this authorization form.

Signature: __________________________________________      Date: _____________________

If this Consent is signed by a personal representative on behalf of patient, complete the following:
Personal Representative’s Name: ___________________________________________________
Relationship to Patient: ___________________________________________________________

This authorization will remain in effect until terminated by the patient, the patient's personal representative, or another individual of legal entity authorized to do so by court order or law.  As stated in our Notice of Privacy Practices, you have the right to revoke or terminate this authorization by submitting a written request to our office.

Signature: ___________________________________________	Date: ___________________ 

Patient Email Address: ____________________________________ (for patient portal)