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.
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.
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