Medical Record Release Form

By signing this form, I authorize you to release confidential health information about the patient named below, by releasing a copy of the medical records, or a summary or narrative of the protected health information, to the person(s) or entity listed below.

Medical Release Form

Name*
First Last
Email*
Date of Birth*
MM slash DD slash YYYY

Please list the patients date of birth
From:
Release the protected health information to the following.*
Agree to release information to Medical Sleep Solutions
By checking this bock you are agreeing to release protected health information to:
Medical Sleep Solutions
1001 Robbie Mince Way
DeSoto, TX 75115
PH: 972-709-7190
Fax: 972-780-4796