Authorization to Release Protected Health Information
Please correct the errors described below.
Sleep Medicine Consultants
5508 Parkcrest Drive, Austin Tx 78731
Telephone 512-420-9900
Fax 512-420-9944
Release Medical Records for:
I hereby authorize:
To release information from my medical record to:
Sleep Medicine Consultants
5508 Parkcrest Drive, Suite 310
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.
Sleep Medicine Consultants
5508 Parkcrest Drive, Austin Tx 78731
Telephone 512-420-9900
Fax 512-420-9944
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