Medical Release

HIPAA Privacy Authorization Form

Authorization for Use or Disclosure of Protected Health Information
(Required by the Health Insurance Portability and Accountability Act, 45 C.F.R. Parts 160 and 164)

Patient’s Full Name:
Address:
City, State & Zip:
Date of Birth:
I authorize:
Doctor’s Name:
Doctor's Address:
City, State & Zip:
Doctor’s Phone:
Doctor’s Fax:
To use and disclose the protected health information described below to Place My Baby and their clients and other individuals involved in my plans for an adoption.

EFFECTIVE PERIOD:
This authorization shall be in force and effect until ten days after the completion of this pregnancy at which time this authorization expires.

EXTENT OF AUTHORIZATION:
I authorize the release of my complete health records (including records related to mental healthcare, communicable diseases, HIV or AIDS, and treatment of alcohol or drug abuse). This medical information may be used by the person I authorize to receive this information as background information pursuant to my plans for an adoption.

I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization. I further understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.
Signature
Date
Month
Day
Year

Medical Release

HIPAA Privacy Authorization Form

I authorize: