Release of Information Form

Westerville Sleep Services

PULMONARY & SLEEP CONSULTANTS, LLC
MEDICAL INFORMATION RELEASE FORM -- HIPAA RELEASE FORM
I hereby authorize the use and disclosure of any and all medical records, including but not limited to records of any substance abuse, psychiatric/mental health information and/or HIVAIDS information of (name of patient and/or person authorized to release information) to/from Pulmonary and Sleep Consultants:
Name*

First NameLast Name
DOB*

MonthDayYear
Date
Phone Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Professional/Organization authorized to send/receive this information (all information must be completed):
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone Number/FAX
For the purpose of:

Continuity of CareInsurance BillingLegal ReasonsTransferring to Another Provider for My CareOther
• I understand that if there is a fee for sending the records that I am requesting, the office will contact me and payment in full will be required prior to sending records.

• This release of information authorization will remain in effect for one year following the date on the form.
Patient Name*
Date*

MonthDayYear
Date
Signature*

Clear
• If someone other than the patient is making this request, please specify name, relationship, and reason for the request.
Name

First NameLast Name
Relationship
Reason for the request
Should be Empty:

Westerville Sleep Services