Notice of Privacy Practices

Our Notice of Privacy Practices provides information about how we may use and disclose the medical information that we maintain about you. It also explains how you can access this information. By signing, you acknowledge that you have reviewed the Notice of Privacy Practices of Proliance Surgeons, Inc., P.S.

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Authorization for the Treatment of a Minor

I authorize Proliance Surgeons Inc. (Puget Sound Ear, Nose & Throat Center) to treat the minor patient named here.

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Emergency Contact

In case of emergency, I authorize PSENT to disclose information and/or review my care with:

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Authorization to Leave Personal Health Information by Alternate Means

Please provide information for all that apply.

With my signature below, I acknowledge and understand that this information will be kept in my medical record and these parameters will be abided by until revoked by me in writing. It is my responsibility to notify my healthcare provider should I change one or more of the telephone numbers provided here.



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The best patient care is put into practice every day at Puget Sound ENT — we consider it a privilege to serve you.
Edmonds

76th Professional Commons
21911 76th Ave W
Suite 211
Edmonds, WA 98026

Fax: (425) 670-6718
Alt Fax: (425) 670-6719
1 (425) 775-6651 Directions
Mill Creek

Swedish Mill Creek Medical Center
13020 Meridian Ave S, 2nd Floor
Everett, WA 98208

Fax: (425) 670-6718
Alt Fax: (425) 670-6719
1 (425) 337-4810 Directions
Puyallup

Ear Nose Throat & Allergy Associates
104 27th Ave SE
Puyallup, WA 98374

entpuyallup.com
*Dr. Backous only

1 (253) 770-9000 Directions
Edmonds Center for Outpatient Surgery (ECOS)

Edmonds Medical Pavilion
7320 216th Street SW, Suite 140
Edmonds, WA 98026

1 (425) 673-3750 Directions