I, _________________________, give Comprehensive Neurology and Sleep Medicine, P.A. (CNSM) permission to discuss the following:

__________________ Diagnosis, prognosis, and/or treatment information
__________________ Test results
__________________ Scheduling information
__________________ Billing and/or insurance information
__________________ Other: (please specify) __________________________________

With the following people:
_______________________________ Relationship _____________________________
_______________________________ Relationship _____________________________

My preferred method to be contacted during daytime hours is:
E-mail______________________ My address is: _______________________________
Daytime phone_______________ My number is:________________________________
I give Comprehensive Neurology and Sleep Medicine permission to leave a message at the above phone number and or email address.

Signature: _____________________________________ Date: ____________________

Note: This form must be complete in order to ensure the confidentially of our patients’ Medical records. This authorization is valid for one year subsequent to the above date.

*Comprehensive Sleep Treatment is a division of CNSM.