Specialist Referral Medical Authorization Release Form
(For Insurance Approvals)
Patient Name
Date of Birth
Patient Phone Number
Patient Address
Insurance Provider
Insurance ID Number
Policy Group Number
Referring Provider Information
Referring Physician Name
Physician Phone Number
Referring Practice
Specialist Information
Specialist Name
Specialty
Specialist Practice Name
Practice Address
Practice Phone Number
Referral Reason / Diagnosis
Medical Records To Be Released
Authorization
Patient/Legal Guardian Name
Signature
Date