Medical Release Form - IMO Sleep Solutions

Welcome

First Name

Last Name

Authorization

I hereby authorize

to release any and all medical records, including but not limited to hospitalization for diagnosis and/or treatment of obstructive sleep apnea. Please include any and all records including all diagnostic and titration sleep studies, office notes, and surgical treatments.

Release to:

Practice: Sleep Better Austin Treatment

Release from:

Doctor:

Practice:

Address:

Phone:

Fax

Uses

The purpose of the release of this information is:

Continuity of Medical Care Other (Specify)

Restrictions

The recipient should not further disclose medical information unless a valid authorization is obtained or unless such use or disclosure is specifically required or permitted by law.

Duration

This authorization will expire 60 days from today or at an earlier date, at my election (To cancel this authorization prior to the above limit, notification must be sent to the Medical Record Department in writing and bear the patient’s or legal representative’s signature.

Patient Information

Patient's Name

Date of Birth

Social Security #

Date(s) of Treatment