"" 1 Medical Records Release Authorization To Whom it May ConcernYour Nameno-icon Please release to A Act of Love/Alternative Options and Services for Children ("Act of Love"), or any employee or agent of Act of Love, 9561 South 700 East, Suite 101 , Sandy, Utah, 84070, copies of all my medical records, including, but not limited to charts, notes, evaluations, test results, invoices and similar documents that you have in your possession. These records are needed by Act of Love in connection with an adoption of my child. I hereby release and absolve you from any and all liability for providing such information to Act of Love. Signatureno-icon Printed Nameno-icon Social Securityno-icon Dateof signaturedate_range NEXT Previous Next
