This SleepSomatics Authorization to Email Medical Records to Patient (the "Authorization") is requested by and voluntarily executed by and for the identified Patient and/or the Patient's legal caregiver, guardian, or duly authorized individual (individually and jointly, "PT") by and between PT and SleepSomatics [together, doing business as SleepSomatics or SleepSomatics Diagnostic Center, SleepSomatics LP (TIN 20-4601197 NPI 1538251202) and EL’Lucre Management Corp (TIN 52-2416115 NPI 1013191386)] whose physical location is 2211 W Parmer Ln, Ste A, Austin, TX, 78727 and whose telephone number is (512) 323-9253 and whose fax is (512) 323-9254 (individually and collectively, "SSDC") for the purposes stated herein (collectively, the "Authorization").
PT understands that authorizing the disclosure of his/her Record is voluntary. PT understands that s/he may inspect or copy the information to be used or disclosed, as provided in CFR 164.524. PT understands that any disclosure of information carries with it the potential for unauthorized re-disclosure and the information may not be protected by federal or state confidentiality or privacy laws. PT understands that the information in PT’s Record may include information relating to sexually-transmitted diseases, acquired immunodeficiency syndrome (AIDS), human immunodeficiency virus (HIV), behavioral and/or mental health services, and treatment for substance abuse. PT understands and acknowledges that email or electronic transmission may not be secure. PT acknowledges and declines the option of postal mailing or PT physical, in-person pickup of PT records from SleepSomatics Diagnostic Center.
PT understands that his/her Record may contain reports, diagnostic and or therapy results, and/or notes that only a physician can interpret or diagnose. PT understands and is advised to contact his/her physician regarding the entries made in PT’s Record to prevent PT misunderstanding of the information contained in his/her Record. PT releases and holds harmless SSDC from any and all liabilities arising out of or resulting from any misinterpretation of the information contained in PT’s Record or as a result of PT not contacting his/her physician for the correct interpretation.
I have thoroughly reviewed and read this Authorization (or waived review and reading) and voluntarily acknowledge, understand, accept, agree to, and execute this entire Authorization.