Medical Record Release Form

Patient Information

Name*

First NameMiddle NameLast Name

Date Of Birth*

Date

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Physician/Organization To Release Information

Name of Physician/Organization*

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Fax Number

Format: (000) 000-0000.

Email

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Physician/Provider/Organization To Receive Information

Name of Physician Receiving Information: Subaila Zia, MD, MBA, FCCP

Name of Organization Receiving Information: Telemedora, PC

Phone: 650-687-7368

Fax: 650-309-1678

Address: 1250 Borregas Ave, Suite 62, Sunnyvale, CA 94089

Please fax the following items:

Office Visit NoteLab resultsSleep study resultsOthers

I understand the information to be released may may include information relating to sexually transmitted diseases, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV), and alcohol and drug abuse. I am giving my consent to release or disclosure this type of informationI understand this authorization is given in compliance with the federal consent requirements for release of alcohol or substance abuse records of 42 CFR 2.31, the restrictions of which have been specifically considered and expressly waived.I understand I have a right to revoke this authorization in writing at any time, except to the extentinformation has been released in reliance upon this authorization.I understand the information released in response to this authorization may be re-disclosed to otherparties.I understand my treatment or payment for my treatment cannot be conditioned on the signing of thisauthorization.I understand any facsimile, copy or photocopy of the authorization shall authorize me to release the recordsrequested herein.I understand this authorization shall be in force and effect until two years from date ofexecution at which time this authorization expires

Name*

First NameMiddle NameLast Name

Signature*

Date*

Date

Medical Record Request Form