Authorization To Receive And Disclose Protected Health Information Authorization To Receive And Disclose Protected Health InformationI authorize Act of Love/Alternative Options and Services For Children to receive and disclose the above-named individual’s health information as described below. (Include dates where appropriate.)Description of information to be used or disclosedDescription[X] Complete Medical Records[X] All PHI in medical record[X] Discharge Summary[X] History & Physical[X] Physician Orders[X] Physician Notes[X] ConsultationsDate(s)All records after: 1/1/2012Description[X] Operative Information[X] Nursing Information[X] Lab Reports[X] Radiology Reports[X] Admission FormDate(s)All records after: 1/1/2012Description[X] Medication Sheets[X] Transfer Forms[X] ER Information[X] X-RayDate(s)All records after: 1/1/2012I understand that this information may include, when applicable, information relating to sexually transmitted disease, Human Immunodeficiency Virus (HIV infection, Acquired Immune Deficiency Syndrome or AIDS Related Complex) and any other communicable disease. It may also include information about behavioral or mental health services, and referral or treatment for alcohol and drug abuse (as permitted by 42 CFR Part 2).This information may be disclosed to and used by the following person or organization.Attorney(s) for adoptive parent(s)Agency for adoptive parent(s)Interstate Compact on the Placement of Children, as necessaryAdoptive parent(s)Court in connection with adoption, as necessaryThis disclosure and use is for the following purpose: Adoption matter.I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing and present my written revocation to the health information management department. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. Unless otherwise revoked, this authorization will expire one year from the signature date.I understand that authorizing the disclosure of this health information is voluntary. I also understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment, payment for services, or eligibility for benefits.By signing this Authorization, I understand that any disclosure of information carries with it the potential for an unauthorized redisclosure and the information may not be protected by federal privacy rules. I further understand I have the right to receive a copy of this signed authorization. I understand and agree that a photo-copy of this authorization shall be granted the same legal force as the original and may be used interchangeably.By signing these documents electronically, I acknowledge that the electronic mark or symbol used to sign is representative of, functionally equivalent to, and shall be treated exactly the same as my handwritten signature. By making such a mark, I affirm that I do so with the intent to sign the forms or records so marked. I understand that by signing these documents electronically I will be bound by the terms of the documents, the same as if I had signed with my handwritten signature. Birth Mother Signature Date A Act of Love ·9561 South 700 East, Suite 101, Sandy, Utah 84070·(801) 572-1696·Fax (801) 572-9303 24-Hour Birth Parent Line 1-800-835-6360 ©Copyright A Act of Love 2010 Please leave this field empty.