Authorization to Release Medical Records

Patient Information

First name

Last name

Birthday

Month

Day

Year

SSN

Information to be released from:

Name of Facility or Provider

Address

Phone

Information to be sent to:

Choice Adoptions

6030 SE 52nd Ave

Suite 205

Porltand, OR 97206

Information to be released

The most recent 2 years of pertinent information

Pregnancy related medical records

All medical records

Other

Specify if clicking "other"

Purpose of disclosure

Attorney

Insurance

Doctor

Personal

Adoption

EXCLUDE the following information from the records released

Drug / Alcohol abuse / treatment & diagnosis

HIV/AIDS diagnosis / treatment / testing

Sexually transmitted disease

Mental illness or psychiatric diagnosis/treatment

Patient Authorization

MY RIGHTS

I understand that I do not have to sign this authorization in order to obtain health care benefits (treatment, payment or enrollment). I may revoke this authorization in writing. To view the process for revoking this authorization, please read the Privacy Notice to patients posted at the facility where your information is being released. I understand that once the health information I have authorized to be disclosed reaches the noted recipient, that person or organization may re-disclose it, at which time it may no longer be protected under Privacy laws.

Signature

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Date

Month

Day

Year

This authorization will expire 180 days from the date signed.

Release of Information to Prospective Adoptive Families

I am in the process of planning for the possible adoption of my child. I hereby authorize Choice Adoptions to share all the information it has collected about me with prospective adoptive parents for the purpose of adoption. This authorization shall be in effect until revoked.

First name

Last name

Birth Parent Signature

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Witness Signature

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Date

Pregnancy Information

First name

Last name

Today's Date

Due Date

Current Pregnancy

Is the baby’s father aware of the pregnancy?

Yes

Unsure

Baby's sex

Female

Male

Unsure

Date prenatal care began for this pregnancy:

Complication of present pregnancy:

Nausea

Vomiting

Excessive Fatigue

Venereal disease

Headaches

Visual disturbance

Urinary infection

Constipation

Bleeding

Vaginal discharge

Anemia

Describe other complications during pregnancy and/or comment on the above-checked complications:

Have you had a previous pregnancy?

Yes

Character of previous pregnancies, deliveries, post-partum, gynecology complications:

Miscarriage

Stillborn

Abortion

Live birth(s)

Explanation of previous pregnancies, including any relevant dates:

Drugs taken during pregnancy:

Non-prescription

Amphetamines

Prescription

Barbiturates

Alcohol

Tobacco

Cocaine (crack)

Heroin

LSD

PCP

Marijuana

IV Drug Use

Methadone

Methamphetamine

Other

Explanation of drugs taken:

PREGNANCY SERVICES INFORMATION SHEET

Date of Referral/Contact with Choice

Today's Date

Due Date

Contact Information

Full Legal Name

Multi-line address

Country/Region

Address

City

Zip / Postal code

Phone

Can we leave identifying messages?

Yes

Company name

Work Phone

May we contact you at work?

Yes

Personal Information

Birthday

Month

Day

Year

Adopted?

Yes

SSN

US Citizen?

Yes

Driver’s License or ID (State & Number)

If not a citizen, passport/visa number

Race/Ethnicity

African American

Asian

Caucasian

Hispanic

Other

If Native American, fill out the following:

Tribe

Location

Blood Degree

Enrollment Number

Marital Status

Married

Divorced

Separated

Single

If married, is your spouse the birth parent?

Yes

If divorced, list the date and court location:

List any other children with their name(s) and date of birth:

For clients under 18

Parents' names

Multi-line address

Country/Region

Address

City

Zip / Postal code

Parent 1 Phone

Parent 1 Email

Parent 2 Phone

Parent 2 Email

Physical Characteristics

Height

Weight

Eye Color

Hair Color

Hair Texture

Skin Color

Biological Father Contact Information

Full Legal Name

Multi-line address

Country/Region

Address

City

Zip / Postal code

Phone (Home/Cell)

Can we leave identifying messages?

Yes

Employer

Work Phone

May we contact at work?

Yes

Is the Biological Father in any branch of the Armed Services of the United States? If yes, list position and location.

Biological Father Personal Information

Birthday

Adopted?

Yes

SSN

US Citizen?

Yes

Driver’s License or ID (State & Number)

If not a citizen, passport/visa number

Race/Ethnicity

African American

Asian

Caucasian

Hispanic

Other

If Native American, fill out the following:

Tribe

Location

Blood Degree

Enrollment Number

Marital Status

Married

Divorced

Separated

Single

If married, is your spouse the birth parent?

Yes

If divorced, list the date and court location:

List any other children with their name(s) and date of birth:

If the Birth Father is Under 18

Parents' names

Multi-line address

Country/Region

Address

City

Zip / Postal code

Parent 1 Phone

Parent 1 Email

Parent 2 Phone

Parent 2 Email

Birth Father Physical Characteristics

Height

Weight

Eye Color

Hair Color

Hair Texture

Skin Color

If Biological Father is not involved in adoption planning:

What is the nature of your relationship with the birthfather?

How long have you known him?

Did you ever live with the biological father? If yes, during what period of time did you live together?

What was your means of financial support during the time you lived together?

Is the birthfather aware of the pregnancy?

Have you been in contact with the birthfather during the pregnancy? If yes, please list the nature of the contact, how contact was made and the dates or approximate dates below:

Medical Information

Medical Coverage

Policy Number

Doctor's Name

Contact Numbers (Phone/Fax)

Multi-line address

Country/Region

Address

City

Zip / Postal code

Hospital Name

Contact Numbers (Phone/Fax)

Multi-line address

Country/Region

Address

City

Zip / Postal code

Counselor's Name

Contact Numbers (Phone/Fax)

Multi-line address

Country/Region

Address

City

Zip / Postal code

Miscellaneous:

Pregnancy-related expenses

Type of adoptive family requested

In general, contact desired after placement

Details or problems

Where did you hear about Choice Adoptions?

What's your availability? (List days and times)

On a scale of 1 to 10, with 1 representing mild interest/curiosity about the adoption option and 10 representing an absolute determination to place your baby for adoption, where would you consider yourself to be at this time?

Advocate's Names

Today's Date

AUTHORIZATION TO USE AND/OR DISCLOSE INFORMATION

PERSON ABOUT WHOM INFORMATION MAY BE RELEASED/DISCLOSED:

First name

Last name

Birthday

Month

Day

Year

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.

Name and address of person or entity authorized to:

Release/send/disclose information to Choice Adoptions

Receive/use information from Choice Adoptions

Insert here:

Information to be Released/Disclosed

By clicking the spaces below, I authorize the release/exchange of the following specific information/records, if such information/records exist:

ICWA (Indian Child Welfare Act) Search

Past and/or current counseling services, including assessments, diagnosis, treatment plans, etc.

Mental health treatment records, including assessment, treatment plan, attendance, and discharge plan

Psychological testing

Medical history, including prescribed medications, current diagnosis, treatment plans and updates, etc.

Educational history, testing and school reports

Drug/alcohol treatment records, including assessment, treatment plan, attendance, discharge plan, drug screens, etc.

Police reports/court documents

Confirmed HIV/AIDS/Hepatitis and/or STD test results

Employment and earnings history

Social History

Other

Add more information for "other"

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:

Date picker

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.

Today's Date

Signature

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