Life Insurance Medical Information Release Form
Personal Information
Full Name
Date of Birth
Address
Phone Number
Authorization
I authorize (Name of Medical Provider or Facility)
to disclose my medical information to (Insurance Company Name)
Purpose of Disclosure
Information to be Released
Expiration & Revocation
This authorization expires on
I understand that I may revoke this authorization at any time by notifying the provider in writing.
Signature
Signature
Date