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:

1. Any and all medical, health, or other information including birth records, birth certificates, or other documentation pertaining to me and my pregnancy.
2. Any and all medical, health, or other information related to drug and/or alcohol use/abuse records.
3. 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.