Authorization to Release Information

TEXAS SLEEP MEDICINE

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

First Name Last Name
Date of Birth *

Month Day Year
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

City State / 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 encounters Other
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 *

Month Day Year
Date
Texas Sleep Medicine

1221 W. Ben White Blvd. 100A

Austin, TX 78704

www.txsleepmedicine.com
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TEXAS SLEEP MEDICINE