Patient Form Submission3. HIPAA AuthorizationPlease complete all applicable fields. An asterisk (*) indicates a required field. Name * First Name Last Name Date of birth * MM DD YYYY Authorization * I authorize the following party/parties: Disclosure * To disclose the following health information: All of my health information The following health information (list in field below) Disclosure details Signature * To Tricoastal Narcolepsy and Sleep Disorders Center, PLLC 11200 Broadway Street, Suite 2743 Pearland, Texas 77584 I understand that I have the right to revoke this authorization, in writing, at any time, except where uses or disclosures have already been made based upon my original permission. I may not be able to revoke this authorization if its purpose was to obtain insurance. In order to revoke this authorization, I must do so in writing and send it to the appropriate disclosing party. I understand that uses and disclosures already made based upon my original permission cannot be taken back. I understand that it is possible that information used or disclosed with my permission may be re-disclosed by the recipient and is no longer protected by the HIPAA Privacy Standards. I understand that treatment by any party may not be conditioned upon my signing of this authorization (unless treatment is sought only to create health information for a third party or to take part in a research study) and that I may have the right to refuse to sign this authorization. I will receive a copy of this authorization after I have signed it. A copy of this authorization is asvalid as the original. I recognize that typing my initials below constitutes my electronic signature authorizing the above. Who signed the form * Self/patient Parent Spouse Guardian Reason someone other than the patient signed If someone other than the patient signed this form, please indicate why in the field below: Thank you!