Application Progress Checklist

  • Step 1 - Primary Application Information

  • Step 2 - Release of Information

    YOU ARE HERE

  • Step 3 - Submit photos and identification

  • Step 4 - Financial Worksheet

  • Step 5 - Declaration Concerning the Biological Father

  • Step 6 - Brief Health History

  • Step 7 - Social Health History

     

     

Release of Information

  • I do hereby give permission for those receiving this release to provide the following agency medical records related to my current pregnancy.

    Heart to Heart Adoptions, National Office
    9669 South 700 East
    Sandy, Utah 84070
    Phone: (801) 563-1000
    Fax: (801) 563-9899

    Medical Records are for the purpose of Adoption.

  • Please deselect any items you do not wish to have disclosed.
  • (If available)
  • (If available)
  • All information I hereby authorize to be obtained from this agency will be held in strictly confidential and cannot be released by the recipient without my express written consent.

    I understand that this authorization will remain in effect for 1 (one) year unless I specified an earlier date above.

    I understand that the information used or disclosed may be subject to disclosure by the person(s) or class of person(s) receiving it and no longer protected by the federal privacy regulations.

    I understand that my confidential information may be released to the adoptive family in a non-identifying manner.

    I understand that I may withdraw this consent at any time as long as the request is made in writing to the above listed medical provider. However, I understand that if I revoke this authorization, it will not have effect on action taken by the above medical provider in reliance on it before my revocation.

    I also understand that refusal to sign this authorization will not prevent my ability to get treatment, payment, enrollment in a health plan, or eligibility for benefits.

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