Release of Information Choice Medical, LLC Ames, IA (515) 232-6000

This can be faxed, emailed to us @ [email protected] or dropped off to our office at 2117 Philadelphia St. Suite 120, Ames, Iowa 50010

2117 Philadelphia St. Suite 120 (515) 232-6000

Ames, IA 50010 (515) 232-2600 Fax

Consent for Release of Information

Patient’s Name: __________________________________________ Date of Birth: _________

Address: _______________________________________________ Phone: _____________

 This information is to be released TO Choice Medical from the facility specified below.

Name of Facility: _________________________________ Phone: ___________________

Address of Facility: ________________________________ Fax: ____________________

 This information is to be released FROM Choice Medical to the facility specified below.

Name of Facility: _________________________________ Phone: __________________

Address of Facility: ________________________________ Fax: ___________________

Check the information to be disclosed:

 Patient Demographics  Prescription for: ___________________

 Physician’s Order  Initial Date of Service: _______________

 Sleep Study  Last Billing Date of Supplies: ___________

 Copy of 30 Day Compliance Download  Last Billing Date of Equipment: _________

 Face to Face Clinical Re-Evaluation  Make/Model of Equipment: ____________

 PT/OT Notes  Serial Number of Equipment: ___________

 Other: _____________  Insurance that Paid for Equipment: _______

Please check the reason for the release below:

 Insurance Claim  Patient Electing to Transfer Providers  Other: _____________________

I have exercised my right to choose the provider of my services. I understand that I can pick any provider that I choose and can switch to another provider at any time. Choice Medical, LLC did not solicit me directly, I contacted them and wish to use their services.

I hereby authorize my physician, hospital or any holder of my medical records to release to agents specified above, any and all information required to determine my benefits. For purposes of receiving information from Medicare this release will be valid for 14 days from date of signature. For all other holders of information, the release will be considered permanent.

Client Signature: ___________________________ Date: ____________________________

Choice Medical Rep: _________________ _______ Date: ____________________________