Patient Release of Records Authorization to Collect Prescription

In reference to all my purchasing of CPAP equipment through LasVegasMedicalStore.com, I hereby authorize the website to directly receive all prescriptions and documentation on my behalf that come with the equipment.

I assume the responsibility to collect the material myself in the event that LasVegasMedicalStore.com is unable to collect my prescription. I am aware of the fact that my shipment will not happen unless and until a prescription is on file.

I also authorize LasVegasMedicalStore.com to release any information required to process my order including medical record or history given by a private practitioner or a hospital. The physician or hospital will not be held liable for the release of such information as it is solely meant for the processing of my order.

Additionally, LasVegasMedicalStore.com is authorized to give a confidential review of my medical record or treatment if there is a requirement to do so by a federal or state agency.

Electronically Signed By …….. on …….. .