Third-Party Medical Information Release Authorization Form
(for Out-of-Network Insurance Claims)
Patient Information
Full Name
Date of Birth
Phone Number
Email Address
Address
Insurance Information
Insurance Company Name
Policy/Member Number
Group Number
Provider Information
Provider Name or Practice
Provider Address
Provider Phone
Authorization
I hereby authorize the above-named medical provider to release my medical information to the third-party insurance company identified above for the purpose of processing my out-of-network insurance claims.
Release all pertinent medical records related to my claim(s)
If limited, specify information authorized for release:
Expiration
Authorization Expiration Date
Other Expiration Condition
Signature
Patient/Guardian Signature
Date
If signed by guardian, print name and relationship to patient: