Quality Urgent Care

quc@qualityurgentcare-riverview.com

(813) 741-2592

Pre-Surgical
Clearance Request

Surgery Being Performed:

Surgery Date:

Patient Name:

Patient Date of Birth:

Self Pay/Worker's Comp Insurance:

Medical Claim #:

Patient Phone Number:

Date of Accident:

Referring Office/Organization

Appointment Date Requested:

Office/Organization Name:

Phone Number:

Fax Number:

Designated Representative Name:

Email Address:

Attorney Information

Is there an attorney assigned to the case?

Yes No

If YES, please provide the following information:

Law Office Name:

Attorney Name:

Phone Number:

Fax Number:

Request for Medical Records

This completed form authorizes that the patient has provided authorization for release of medical records information necessary for billing or continuity of care. If there are specific records needed for this patient, please check information to be released:

All Records Diagnostic Imaging Progress Note EMC Form Lab Report

Preferred method to receive requested records:

Secure Fax at:

Mail to: Attn:

Quality Urgent Care

Pre-Surgical
Clearance Request

Referring Office/Organization

Attorney Information

Requested Services

Testing

Lab Work

Request for Medical Records