Authorization For Disclosure of Medical Information

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.

Notice of Privacy Practices

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.

Privacy Practices

This document describes how medical information about you may be used and disclosed, and how you can get access to this information.

Registration Form

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.

Medication History Authorization

By signing this form, you are giving permission to your doctor to access your prescription history

Medical Questionnaire

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.

Sleep Questionnaire

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.

Department of Motor Vehicles Application for Disabled Person Placard or Plate

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.

DNR Form

A DNR is a request not to have cardiopulmonary resuscitation (CPR) if your heart stops or you have stopped breathing.

Health Care Directive

This form allows you to designate someone to make health care decisions for you when you are unable.

Physician Orders for Life-Sustaining Treatment (POLST) Form

Don't have the Adobe Acrobat Reader? Click the button below to download.

Get Acrobat Reader

65 North 14th Street, San Jose, CA 95112   •   (408) 279-1400 phone   •   (408) 279-3216 fax