Authorization to Release Information

TEXAS SLEEP MEDICINE

Phone: 512-440-5757 Fax: 512-440-5858
AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Email*
example@example.com
I request and authorize the healthcare provider or facility to release healthcare information of the patient named above to Texas Sleep Medicine. Fax # 512-440-5858.

Name of facility:*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PHONE NUMBER*
Please enter a valid phone number.
FAX NUMBER*
Please enter a valid phone number.
Released information*

All sleep studies and related provider encountersOther
Reports may include information on drug, alcohol, psychological, or communicable disease. I waive the priviledge of confidentiality of this information. I understand that I may revoke this consent at any time except to the extent that action has already been taken on it and that in any event, this authorization expires automatically in ninety days from the date of signature or as otherwise specified.
This faxed document may contain confidential medical records. Disclosure of this information to anyone but the intended recipients is prohibited by law, and will result in criminal or civil penalties.
Signature*

Clear
Date*

MonthDayYear
Date
ACCREDITED BY THE AMERICAN ACADEMY OF SLEEP MEDICINE

South Office North Office

1221 W. Ben White Blvd. A100 8500 Bluffstone Cove A101

Austin, TX 78704 Austin, TX 78758

Phone: (512) 440-5757 Fax:(512) 440-5858

WWW.TXSLEEPMEDICINE.COM
Should be Empty:

TEXAS SLEEP MEDICINE

AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION

Name of facility:*