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This form is used to give your authorization to South Bay Respiratory Associates to release your medical records to another physician and/or organization, or to obtain your medical records from another physician and/or organization. This form with your signature confirms that you have read and understood our Privacy Policy protecting your health information, Please download and sign this form, and bring it with you at your first visit. This document describes how medical information about you may be used and disclosed, and how you can get access to this information. This form includes personal information about you, insurance information, and gives us authorization to treat you and to bill and accept assignment for payment from your insurance company(s). Please download this form, complete and sign, and bring with you to your first visit.
By signing this form, you are giving permission to your doctor to access your prescription history This form provides an overview of your medical history and family medical history to the physician, and is instrumental in providing your physician with the information necessary for him/her to begin your patient/physician relationship. Please complete this form as detailed as possible, and bring it with you to your first visit. This sleep questionnaire provides useful information for patients seeking help with sleep disorders. If you are scheduled for a sleep consultation, please print and bring this completed form with you for your first visit.
Download this form to apply for the Disabled Person Placard or Plate, and mail it to the Department of Motor Vehicles address shown on the form. A DNR is a request not to have cardiopulmonary resuscitation (CPR) if your heart stops or you have stopped breathing. This form allows you to designate someone to make health care decisions for you when you are unable.
Don't have the Adobe Acrobat Reader? Click the button below to download. 65 North 14th Street, San Jose, CA 95112 • (408) 279-1400 phone • (408) 279-3216 fax
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