To furnish to: Adoptions With Love, Inc., 246 Walnut Street, Suite 103, Newton , MA 02460, all records and reports, including but not limited to x-rays, photo static copies, abstracts or excerpts of all records, including any information which it may request relating to an examination, treatment, opinion or evaluation concerning any condition that I may have or have had in the past including:
- Behavioral health information
- Genetic Testing and results
- AIDS/ARC and/or HIV testing results
- Immunization records
I authorize the above-named pediatrician to release information pertaining to the health and well-being of my child. This authorization allows the information obtained by Adoptions With Love, Inc. from the above-mentioned medical provider, to be given to the prospective adoptive parent(s) that has/have been selected for my child. I am aware that all identifying information, such as name, social security number and medical record number, will be deleted from the copies given to the prospective adoptive parent(s).
I understand that information used or disclosed pursuant to this authorization could be subject to redisclosure by the recipient and, if so, may not be subject to federal or state law protecting its confidentiality. I know that this authorization is voluntary. I understand that treatment will not be conditioned on the completion of the authorization.
I understand that I may refuse to sign or may revoke (at any time) this authorization for any reason and that such refusal or revocation will not affect the commencement, continuation, or quality of my treatment at (entered below).
This authorization is valid for 180 days from the date of its execution and may be revoked by me by a written notarized statement to the healthcare provider disclosing the records, at any time prior thereto, except to the extent action has been taken in reliance on this authorization.
A photocopy or fax of this authorization shall have the same force and effect as the original.
Your full assistance and cooperation are respectfully requested. By my signature below, I hereby knowingly and voluntarily authorize (entered below) to disclose my health and my child's health information in the manner described above.