Older Child Medical Release

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 above named medical practitioner or facility or related entity to give Lifetime Adoption:

1. Any and all medical, health, or other information including birth records, birth certificates, or other documentation, and immunization records and well child/office visits pertaining to my child.
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.
4. Any and all school records including daycare and preschool records.

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 understand I have the right to receive a copy of the records.
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.