Authorization to Release Protected Health Information

Please correct the errors described below.

Release Medical Records for:

I hereby authorize:

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.

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

Your information will be encrypted.