Release of Information Form

Consent to Release Medical Information and Election to use O2Neal Medical, Inc. as my DME supplier of choice.

ONeal Medical dba CPAP Plus
Patient Name*

First NameLast Name
Patient Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient Date of Birth*

MonthDayYear
Patient Email

Confirmation Emailexample@example.com
Type of Information to be Released
I authorize O2Neal Medical, Inc. to receive copies of all of my medical records, including, but not limited to progress notes, operative notes, laboratory results, sleep studies, prescriptions, and diagnostic tests. Disclosure of personal health information will be handled as outlined in O2Neal Medical, Inc.’s Current Notice of Privacy Practices. A photographic copy of this authorization shall be as valid as the original. This authorization is valid until cancelled in writing by either party. This release shall be valid while services are being rendered from O2Neal Medical, Inc., unless cancelled in writing.
Purpose for Information Release
The purpose of this release is to elect and establish service with O2Neal Medical, Inc. for my durable medical equipment equipment and supplies. I direct my existing DME supplier to fully cooperate in the timely transfer of records to O2Neal Medical and further request a copy of the pickup ticket of the equipment from my current supplier be sent to O2Neal as well and in a timely manner.


Please send my documents within 2 business days by faxing them to 205-989-9903. Time is of the essense.
Consent*

I understand that this release is valid when I sign it and that I may withdraw my consent to this release at any time in writing to O2Neal Medical, Inc.
Signature*

Clear
Date Signed*

MonthDayYear
Date
Should be Empty:

Consent to Release Medical Information and Election to use O2Neal Medical, Inc. as my DME supplier of choice.