Spring Hill Primary Care
Patient Name
Date of Birth
Phone (Home)
Phone (Work)
Address
City / State / Zip
Facility Name
Facility Phone
Facility Fax
Facility Address
Change of Insurance or PhysicianContinuation of CareReferralOther
If Other, please specify
2 years prior from last date seenOther dates
If Other Dates, specify
Specific Information Requested
Expiration Date (if any)
Signature (Type Full Name)
Date Signed
Printed Name of Authorized Representative (if applicable)
Relationship to Patient
Address & Phone of Authorized Representative
I have read and understand the Authorization for Release of Medical Information.