Records Permission | Acknowledgement

Records Permission | Acknowledgement
Patient Name:

First NameLast Name
Patient Date of Birth:

MonthDayYear
Date
I give Red River Sleep Center, Inc., its staff and its members permission to speak with the people/service providers/organizations listed below regarding: my health status (including: diagnosis, treatment options, plans/payment for health services I receive), contact information (including: names, addresses, email, phone/fax numbers), dates (including: DOB, dates of service, other), and personal information (including: social security number, account numbers, codes

This consent is valid until such time as I provide Red River Sleep Center, Inc. written revocation of it. Name and relationship of spouse and parents must be listed to be legally recognized.
List of Persons & Organizations Approved to have access to my private health information.
Name 1*
Person/Organization 1
Relationship*
Person/Organization 1
Name 2
Person/Organization 2
Relationship
Person/Organization 2
Name 3
Person/Organization 3
Relationship
Person/Organization 3
Name 4
Person/Organization 4
Relationship
Person/Organization 4
Name 5
Person/Organization 5
Relationship
Person/Organization 5
List of Approved Email, Fax, and Medical Providers
Email records to:
example@example.com
Fax Number (Grant permission to fax records to this number):
Physicians/Medical Providers
Physicians/Medical Providers
Acknowledgement of Privacy Practices
I have been presented with the Red River Sleep Center, Inc. Notice of Privacy Practices, detailing how my information may be used and disclosed as permitted under federal and state law. I understand the contents of the Notice, and I request the following restrictions(s) concerning the use of my personal medical information:

Further, I permit a copy of this authorization to be used in place of the original, and request payment of medical insurance benefits either to myself or to the party who accepts assignment. Regulations pertaining to medical assignment of benefits apply.
Signature*

Clear
Date*

MonthDayYear
Date
(THIS FORM IS TO BE FILED IN THE PATIENT’S MEDICAL RECORD AND WITH THE INSURANCE/BILLING)
If the patient refuses to sign, indicate your attempt to obtain a signature below.

Patient refused to sign this acknowledgement form.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Records Permission | Acknowledgement

List of Persons & Organizations Approved to have access to my private health information.

List of Approved Email, Fax, and Medical Providers

Acknowledgement of Privacy Practices