Authorization to Release Information

* = Required Fields

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*	*Invalid Number
Date of Birth*	*Invalid Date
Mailing Address*	*
City/State/Zip Code* City * State AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY * Zip Code - ***
Home Phone Number	() - ***
Cell Phone	() - ***
Email Address*	*Invalid Email
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*	*Invalid Number
Section 4: Additional Information
Notes
Section 5: Entity Authorized to Receive Information
Organization Name
Contact Person*	*
Phone Number	() - ***
Fax Number	() - ***
Email Address*	*Invalid Email
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	Invalid Date
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