Medical Release Form | Commonwealth Sleep Center

Patient Information

Date

Name

First

Middle

Last

Date Of Birth

Age

Social Security

Address

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Work Phone

EXT

Mobile Phone

Email *

Please check the information you are requesting

Checkboxes

Office Visit Notes
Sleep Study Reports
All Records

do hereby authorize Commonwealth Sleep Center to release or get

PLEASE CHECK ANY ONE OF THE OPTION:

RELEASE OR
GET RECORDS FROM

Name of company / agency / facility / person

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number

Fax Number

Purpose of disclosure:

I hereby authorize disclosure of the health information above. This authorization is valid for 12 months from the date of signature. I understand that I may cancel this request with written notification, but that it will not affect any information release prior to notification of cancellation, I understand that the information used or disclosed may be subject to re-disclosure by the person or class of person or facility receiving it and would then no longer be protected by federal regulations.

****** Note: There will be a charge for personal copy and permanent transfer of your records *****