Please enable JavaScript in your browser to complete this form.RELEASE OF INFORMATIONHEART TO HEART ADOPTIONS 9669 S 700 E Sandy Utah 84070 PHONE: 801-563-1000 FAX: 801-563-9899 The person signing this is requesting Medical Records to be sent to HEART TO HEART ADOPTIONS at the address/fax shown above for the purpose of ADOPTION.Medical Provider InformationNameHospital NameHospital Phone NumberDoctor NameDoctor Phone NumberFor the Medical Records of: Full NameDate of Birth Social Security NumberRecords RequestedAll medical information/reportsX-ray and Laboratory reportsPsychological testingPrenatal medical recordsMedical data for WIC certificationOther (specify): Billing, patient/client accounts, all other reports/recordsConsent to test & release HIV test resultsPhysical examination reportsImmunization recordsConsent to test and release Alcohol and Drug screeningInformation pertaining to MedicaidAll 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 specify an earlier date here: NONE 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 me 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.I do hereby give permission for those receiving this release to provide Heart to Heart Adoptions medical records related to my current pregnancy.Please Sign HereClear SignatureSign DateSubmit