HEART 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 Information

Full Name

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 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.