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Birth Parent - Medical Provider Contact Information

  • Please complete the following listing information about medical care you have received.
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • If you have Medicaid, please complete the following:
  • Date Format: MM slash DD slash YYYY
  • I, the undersigned, authorize Medicaid in the state listed above to give information about my case to Heart to Heart Adoptions.
  • Date Format: MM slash DD slash YYYY
  • We understand that, in some circumstances, it might not be a good idea to have proof of your communication with us in your inbox. So, please let us know your preference below.
  • This field is for validation purposes and should be left unchanged.
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