METROPLEX PULMONARY & SLEEP CENTER, P.A
4833 Medical Center Drive, Suite 6B McKinney, Texas 75069
Phone: 972- 838-1892 Fax: 972-838-1896 or 972-954-6030
You can request your medical records to be mailed to your house. We will send those to you by USPS Certified mail
and with signature confirmation. However, you must send us a written and signed request if you wish to receive
your medical records via email.
Who do you authorize to talk to us on your behalf in your absence?
I request that payment of authorized insurance benefits be made on my behalf to Metroplex Pulmonary and Sleep
Center for any services furnished by the provider. I authorize any holder of medical information about me to release
to the Health Care Financing Administration, and its agents any information needed to determine these benefits or
the benefits payable for related services. I understand my signature requests that payment be made and authorizes
release of medical information necessary to pay the claim. If "other health insurance" is indicated in item 9 of the
HCFA-1500 form, or elsewhere on other approved claim forms or electronically submitted claims, my signature
authorizes releasing of the information to the insurer or agency shown.