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.

This Authorization is subject to the SleepSomatics Terms of Use (Website), SleepSomatics Privacy Policy and Patient Bill of Rights, SSDC Service(s) Consent, Member Authorization Form for a Designated Representative to Appeal a Determination, SSDC Additional Disclosures, SSDC Consent for Use and Disclosure of PT Health Information – HIPAA and Privacy Notice, and SSDC Authorization to Release PT Medical Records and may all be accessed at sleepsomatics.com or by requesting a printed copy by calling SleepSomatics at (512) 323-9253.

By executing this Authorization, I confirm that I am the identified PT. I am initiating an electronic signature to confirm my acknowledgement, understanding, and acceptance of this Authorization. My electronic signature is made in accordance with the Electronic Signatures in Global and National Commerce Act (ESIGN) and the Uniform Electronic Transactions Act (UETA). I understand that misrepresentation of my identity is a federal crime. I further understand that by signing below, I am accepting and agreeing to the SleepSomatics Terms of Use, which is available to me at sleepsomatics.com. I may request a free printed copy by calling SleepSomatics during daytime administrative hours. I acknowledge and agree that my execution of this Authorization and my signature for said execution shall be valid for twelve (12) months from the date of my execution of this Authorization for all Service(s) provided by SSDC to me during said twelve (12) months.

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.