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Authorization to Release Information

Section 1: Information Needed

Please check all that you are requesting *

Claim History

Professional Liability Coverage

Section 2: Applicant Information

Last Name *

First Name *

Middle Name/Initial

Maiden Name (if applicable)

Last Four Digits of Social Security Number *

Date of Birth *

Mailing Address *

City/State/Zip Code *

Home Phone Number

Cell Phone

Email Address *

Section 3: Status While at UMMC

Department *

Dates of Employment (MM/DD/YY to MM/DD/YY)

Status while at UMMC (e.g., CRNA, MD, PhD, resident) *

UMMC Employee ID Number *

Section 4: Additional Information

Notes

Section 5: Entity Authorized to Receive Information

Organization Name

Contact Person *

Phone Number

Fax Number

Email Address *

Authorization

Signature Check *

By clicking this checkbox and submitting this form, I acknowledge that this check represents my digital signature and carries the full legal authorization as if I had signed my name.

Date