Medical Records Release Authorization

To Whom it may concern:

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.

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.

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