AUTHORIZATION TO USE AND/OR DISCLOSE INFORMATION

PERSON ABOUT WHOM INFORMATION MAY BE RELEASED/DISCLOSED:

I, the undersigned, hereby authorize

Choice Adoptions

6030 SE 52nd Ave

Suite 205

Portland, OR

97202

and the following named persons or entities to release and/or disclose to each other and exchange copies of any and all records or other information either may have about the person named above, and to fully discuss this information, as indicated below.

Information to be Released/Disclosed

Purpose of Disclosure

To assist in ongoing adoption assessment, service, planning, and case coordination.

Form of Disclosure

Unless the undersigned has specifically requested in writing that disclosure be made in a specific format, information may be released or disclosed in any manner that is expedient, appropriate, and consistent with applicable law, including, but not limited to, orally, in paper format, or electronically.

Revocation

The undersigned may revoke this authorization at any time by sending written notification to the appropriate adoption case worker at Choice. Any revocation will not affect any actions taken before the revocation was received or actions taken based on the previously shared information.

Expiration

Unless sooner revoked, this authorization will expire one year from the date indicated below or as otherwise indicated:

Release of Liability

I, the undersigned, release Choice Adoptions and the above-named persons or entities from all legal responsibility or liability that may arise from the acts that I have authorized herein. I acknowledge that the information to be released may include confidential information which could not be released without this written consent, including information that is specific to adoption counseling; family planning; employment; drug, alcohol or psychiatric treatment; and/or HIV testing and diagnosis.

Validity/Copies

In order to be valid, this authorization must be filled out completely and signed. A copy of this form will be considered as valid as an original, provided that the copy has not been altered.

Additional Understandings

I understand the following:

I may request a copy of this form after I sign it. I may request or inspect a copy of any information to be used and/or disclosed under this authorization, in accordance with the applicable law and policy of the organization providing or receiving the information.

Federal and State privacy regulations do not apply to all persons and entities. Therefore, if I authorize disclosure of information, that information may not be protected. Choice Adoptions cannot prevent any person to whom it releases information from re-disclosing that information to a third party.