My Source : Patient Release Form

My SourceSM: Patient Release Form
P.O. Box 4133
Gaithersburg, MD 20855 - 4133
Phone: 1-800-676-4266
Fax: 1-844-727-2757
Patient Information:
Patient Name:
Date of Birth (m/d/y):
SS # (last 4 digits):
Address:
City:
State:
ZIP:
Phone Number:
Male
Female
Insurance Information:
Primary Insurance Company:
Phone Number:
Policy Number:
Group Number:
Policy Holder Name:
Policy Holder Date of Birth:
Secondary Insurance Company:
Phone Number:
Policy Number:
Group Number:
Policy Holder Name:
Policy Holder Date of Birth:
Physician Information:
Physician Name:
Phone Number:
Clinic Name:
Clinic Contact:
The information on this form is accurate and complete. I hereby authorize my healthcare providers,
health plans, and insurers to release medical and other pertinent information to Covance Market Access
Services and/or its authorized designee for the sole purpose of determining medical insurance benefits.
Patient’s Signature:
(or Legal Guardian)
Date (m/d/y):
Confidentiality:
Confidentiality related to patient information is of utmost importance. Representatives of Covance Market Access Services and/or its
affiliate companies and the aforementioned healthcare provider, by recognition of this form, state their compliance with federal, state, and
local guidelines regarding patient confidentiality rights.
My SourceSM is a service mark of CSL Behring LLC.
COA13-06-0025(1) 10/2015