Randy Morton, M.D.
3209 North Fourth Street, Suite 300
Longview, Texas 75605 (903) 753-7205

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PATIENT HEALTH INFORMATION DISCLOSURE AUTHORIZATION

I authorize Randy L. Morton, M.D. to leave information regarding my appointments and/or billing on my home answering machine. YES / NO

I have read and received the NOTICE OF PRIVACY POLICIES for Randy L. Morton, M.D.
YES / NO

I authorize Randy L. Morton, M.D. to discuss my health information, appointments and/or billing with the following:

Please circle your choice(s):
SPOUSE / SON / DAUGHTER / OTHER
Please write the name(s) of your choice(s) below:

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Signature of patient or responsible party: ______________________________

Date:_________________________