International Travel Medical Authorization Release Form

(for Overseas Insurance Providers)

1. Personal Information

Full Name

Date of Birth

Passport Number

Nationality

Contact Number

Email Address

2. Emergency Contact Details

Contact Name

Relationship

Contact Number

Email Address

3. Travel Information

Destination Country

Departure Date

Return Date

4. Medical Information Existing Medical Conditions Current Medications Allergies

5. Authorization and Consent

I hereby authorize release of my medical information as necessary to overseas insurance providers for the purpose of processing medical or travel-related claims during my international travel.

I give my consent.

Signature

Date