Dubuque Neurology and Sleep Medicine, P.C.

Available Forms

Authorization to Allow Access to the Electronic Medical Record Authorization to Release Medical Records Demographic Information Terms and Conditions of Up Dox Patient Portal

Authorization to Allow Access to the Electronic Medical Record

Patient full legal name *

Patient Date of Birth *

Gender *

City *

State *

Zip Code

New Field7

I understand that by signing this form I am requesting access to my electronic medical record. I agree to the terms and condition of the Up Dox Patient Portal which can be found at http://dnsm.myupdox.com. I understand that this access will be in effect until such time that I notify the Director of Health Information Management at the address below, in writing, to terminate this access. Access to Up Dox can be revoked at any time. Your request will be processed within 3 business days of receipt, further instructions will by sent via the U.S. mail.

Patient Signature *

Date *

Mail Completed forms to - Dubuque Neurology & Sleep Medicine, P.C. - 2140 John F. Kennedy Road, Suite C - Dubuque, Iowa 52002

Fax completed forms to 563-583-0443

Questions may directed to 563-583-1558

* Required field