Authorization to Release Protected Health Information

Release Medical Records for:

Patient Name:

Patient Date Of Birth

If Minor, Parent or Guardian's name:

Patient Mailing Address:

Patient Email Address:

Patient Phone Number:

I hereby authorize:

Facility Name:

Address:

Phone Number

Fax Number and/ or email address

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

Check all the apply:

History and Physical/ Consultation Visit

Sleep Studies

Labs

All Records

List any limitations on information:

E-Signature of Patient or Legal Representative

Your information will be encrypted.