SLEZ03 Medical Release Form

Authorization to Release Protected Health Information

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Patient Name*

First NameMiddle NameLast Name

Date of Birth*

Date

If Minor, Parent or Guardian's name

First NameLast Name

Patient Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Patient Email Address*

example@example.com

Patient Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

I hereby authorize:

Facility Name*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Fax Number and/ or email address*

To release information from my medical record to:

Sleep Medicine Consultants

5929 Balcones Drive, Suite 303

Austin, Texas 78731

Ph: (512) 420-9900 Fax: (512) 420-9944

By signing this form I authorize the release of my confidential health information. This information may be released by means of a copy of my medical records or a summary/narrative of my protected health information as indicated below.

Check all the apply

History and Physical/ Consultation VisitSleep StudiesLabsAll Records

List any limitations on information

This release is to be in effect until I contact the office and terminate.

Digital Signature Authorization:*

I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.

Signature of Patient or Legal Representative