Surgery Pre-Authorization Release Form
Patient Information
Full Name
Date of Birth
Phone Number
Address
Email
Physician/Surgical Information
Physician Name
Facility/Hospital
Planned Surgery/Procedure
Surgery Date
Surgery Time
Insurance & Authorization
Insurance Provider
Policy Number
Pre-Authorization Number (if available)
Patient Authorization
I authorize the release of medical information necessary for the processing of my surgery pre-authorization request with my insurance provider.
Additional Notes
Patient Signature
Date