Older Child Medical Release
Per the Health and Human Services Department of the United States and pursuant to the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I hereby authorize the above named medical practitioner or facility or related entity to give Lifetime Adoption:
- Any and all medical, health, or other information including birth records, birth certificates, or other documentation, and immunization records and well child/office visits pertaining to my child.
- Any and all medical, health, or other information related to drug and/or alcohol use/abuse records.
- Any and all medical, health, or other information related to mental illness other than counseling or psychotherapy notes.
- Any and all school records including daycare and preschool records.
I understand this information may be used in considering, planning for, or in connection with proceedings in preparation of an adoption plan for my child. I understand I have the right to receive a copy of the records.
I am signing this release voluntarily, and I understand I have the right to revoke my consent, which expires nine months from the date of signature.
I understand that this information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient to parties involved in the adoption process and is no longer protected by Federal Law.