Surgical Procedure Medical Authorization Release Form
(For Pre-Approval Insurance)
Patient Information
Full Name
Date of Birth
Address
Phone Number
Insurance Provider
Policy / Member ID Number
Treating Physician Information
Physician Name
Physician Contact
Physician Address
Procedure Details
Name of Surgical Procedure
Proposed Date
Hospital / Facility
Reason for Procedure
Medical Authorization and Release
I hereby authorize my treating physician and the facility to release all pertinent medical information relevant to my surgical procedure to my insurance provider for the purpose of pre-approval. I understand this authorization is necessary to proceed with my insurance claim.
Patient Signature
Date