Authorization to Release Health Information This document authorizes Pulmonary & Sleep Specialists, PC to release health information from the records of:Name* First Last Date of Birth* MM slash DD slash YYYY Records are to be released to:Name of receiving person/organization Address or Fax #Specify records to be released Office notes Sleep study Lab Radiology Other Specify other records to be released Patient or Representative InitialsEnter initials in each boxInitials: info may be disclosed I understand that information released by this authorization may be disclosed by the recipient to the entity/entities indicated above.Initials: right to revoke I understand that I have the right to revoke this authorization, in writing, at any time by sending such written notification to the practice at:Pulmonary & Sleep Specialists, PC2665 North Decatur Road, Suite 230 Decatur, Georgia 30033Initials: revocation not effective I understand that a revocation is not effective to the extent that my physician may have already disclosed the health information in accordance with previously signed authorizations.Initials: agree to pay I agree to pay a reasonable cost to cover this service.Initials: place no limitation I place no limitation on release of history of illness or diagnostic and therapeutic information.Initials: end of authorization I understand that this authorization ends in 1 year unless otherwise stated below.when this authorization will end Signature* Patient or Legal RepresentativeDate MM slash DD slash YYYY Patient Representative Parent/Guardian of Minor Patient Guardian/Conservator Next of Kin/Executor of Deceased