Medical Record Release and Authorization
In order to provide the best help possible for your adoption plan, we’ve provided a way to sign a medical release digitally.
Per the Health and Human Services Department of the United States and pursuant to the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I hereby authorize the person/organization allowed to disclose information to give Lifetime Adoption:
- Any and all medical, health, or other information including birth records, birth certificates, or other documentation pertaining to me and my pregnancy.
- Any and all medical, health, or other information related to drug and/or alcohol use/abuse records.
- Any and all medical, health, or other information related to mental illness other than counseling or psychotherapy notes.
I understand this information may be used in considering, planning for, or in connection with proceedings in preparation of an adoption plan for my child.
I am signing this release voluntarily, and I understand I have the right to revoke my consent, which expires nine months from the date of signature.
I understand that this information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient to parties involved in the adoption process and is no longer protected by Federal Law.
Lifetime Adoption, Inc. is a Licensed Florida Child Placing Agency. (License #100096562)
Lifetime Adoption, Inc. is a Licensed Florida Child Placing Agency. (License #100084254)
Lifetime Adoption Center is a BBB Accredited Business with an A+ rating
Copyright © | Lifetime Adoption