Chronic Illness Treatment Medical Authorization Release Form
(for Ongoing Insurance Claims)
Patient Full Name
Date of Birth
Address
Phone Number
Insurance Policy Number
Treating Physician / Practice
Physician Address
Physician Phone Number
Description of Chronic Illness or Condition
Treatment(s) Authorized/Received
Medical Records and Information Authorized for Release
To Be Released To (Name of Insurance Company/Adjuster)
Recipient Address
Purpose of Release
Authorization Period
From
To
Additional Instructions/Limitations (if any)
Patient Signature
Date