In an effort to ensure timely and safe care for our patients, we’re pleased to announce the offering of Telemedicine at Bergen Ear, Nose & Throat Associates.




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  • I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form. In accordance with New Jersey State Law and the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I understand that: This authorization may include disclosure of information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH TREATMENT, except psychotherapy notes, and CONFIDENTIAL HIV* RELATED INFORMATION only if I place my initials on the appropriate line item 9(a), I specifically authorize release of such information to the person(s) indicated in Item 8. If I am authorizing the release of HIV- related, alcohol or drug treatment, or mental health treatment information, the recipient is prohibited from redisclosing such information without my authorization unless permitted to do so under federal or state law. I understand that I have the right to request a list of people who may receive or use my HIV-related information without authorization. If I experience discrimination because of the release or disclosure of HIV-related information, I may contact the New Jersey Division on Civil Rights (973) 977-4500. This agency is responsible for protecting my rights. I have the right to revoke this authorization at any time by writing to the health care provider listed below. I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization. I understand that signing this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditioned upon my authorization of this disclosure. Information disclosed under this authorization might be redisclosed by the recipient (except as noted above in item 2), and this redisclosure may no longer be protected by federal or state law. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CARE WITH ANYONE OTHER THAN THEN ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9(b).
  • Specific information to be released

  • Authorization to Discuss Health Information

  • By initialing here
  • I authorize to discuss my health information with my attorney, or a governmental agency to discuss my health information with my attorney, or a governmental agency
  • All items on this form have been completed and my questions about this form have been answered. In addition, I have been provided a copy of the form.
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