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Patient Forms

Sleep Log / Diary (adult)

Sleep Log / Diary (adolescent)

Epworth Sleepiness Scale

Epworth Sleepiness Scale (Modified)

HIPAA Acknowledgment / HIPAA authorization form

Medical Records Release Form (to send your records out)

Medical Records Release Form (to send outside records to us)

HIPAA Policies and Privacy Notice

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240-560-2230

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10221 River Road, #61324, Potomac, MD 20859 www.healthysleepinstitute.com 240-560-2230 Fax 1-800-886-1005
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