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Your First Name
Your Last Name
Authorization For Release of Protected Health Information
Patient/Plan Member Name
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Birth Date
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Nameyour full name
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Social Security No.
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Address
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City
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State
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Zip
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Requester's Name/ Relationship to Patient
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Health Care Provider's Name/Address
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Purpose of Disclosure
I authorize the release of my protected health information listed below by the health care provider listed above to Act of Love Adoptions. I also authorize the release of my protected health information to other adoption agencies involved with the placement of my child for adoption, the adoptive parents, the attorney for the adoptive parents, any courts in connection with the adoption, any administrator for the Interstate Compact on the Placement of Children, as needed, and any other person Act of Love Adoptions deems necessary for purposes of completing my adoption plan.
Description of information to be used or disclosed
Description
Dates
[X] Complete Medical Records
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[X] All PHI in medical record
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[X] Discharge Summary
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[X] History & Physical
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[X] Physician Orders
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[X] Physician Notes
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[X] Operative Information
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[X] Nursing Information
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[X] Lab Reports
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[X] Radiology Reports
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[X] Admission Form
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[X] Medication Sheets
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[X] Transfer Forms
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[X] ER Information
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[X] X-Ray
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Other
Specify
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The following information is to be released when included in the above, unless I have indicated otherwise below:
I understand that:
1. I may refuse to sign this authorization and this it is strictly voluntary.
2. If I do not sign this form, my health care and the payment for my health care will not be affected unless stated otherwise.
3. I may revoke this authorization at any time in writing, but if I do, it will not have any effect on any actions taken prior to receiving the revocation. Further, details may be found in the Notice of Privacy Practices.
4. If the requester or receiver is not a health plan or health care provider, the released information my no longer be protected by federal privacy regulations and may be redisclosed.
5. I understand that I may see and obtain a copy of the information described on this·form, for a reasonable copy fee, if I ask for it.
6. I may get a copy of this form after I sign it.
This authorization shall expire on this expiration date:
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If I fail to specify an expiration date or event, this authorization will expire six (6) months from the date on which it was signed.
I have read the above and authorize the disclosure of the protected health information as stated.
Signature of PatienUPlan Member/Guardian/PatienUPlan Member Representative:
Name
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Dateof signature
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Print name of PatienUPlan Member's Representative:
Name
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Relationship to Patient/Plan Member
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A PHOTOCOPY OF THIS AUTHORIZATION MAY BE USED THE SAME AS AN ORIGINAL
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