Patient Consent
I hereby consent to the disclosure of my response to the Sleep Apnea Questionnaire for the purpose of assisting in the diagnosis and treatment of a potential sleep disorder. I understand that as a part of this organization’s treatment, payment, or health care operations, it may become necessary to disclose my protected health information to another entity, and I consent such disclosure for the permitted uses, including, but not limited to, disclosures via fax. I fully understand and accept the terms to this consent. |