Expectant Mother Release of Information

    Patient Information

    Authorization For Release of Information

    I hereby authorize any physician, nursing staff, medical facility, psychiatrist, psychologist, adoption agency, attorney, or federal, state, county or city agency to release any and all:

    • psychological, psychiatric, health information or diagnoses pertaining to me or my unborn child, including the gender of my child (even if I choose to not know myself) as well as my drug test results and information related to HIV, and other communicable diseases
    • birth certificate for myself or the child I am placing for adoption
    • Medicaid number and any other information about my case

    I authorize A Guardian Angel Adoptions, LLC to release my non- identifying information to the individual or couple that adopts my child, as identified by the “Placement Agreement” between A Guardian Angel Adoptions, LLC and the adoptive parent/parents.

    I also authorize A Guardian Angel Adoptions, LLC to release my information to legal counsel as well as court officials for finalization of my child’s adoption.

    I request that my information may be released to:
    A Guardian Angel Adoptions, LLC
    P.O. Box 95902
    South Jordan, Utah 84095
    Phone: (801) 756-7757 Fax: (801) 568-0567

    I Understand

    * I may revoke this authorization by providing a written statement to the provider except to the extent that the provider has already acted upon it.

    * The provider will not condition treatment on my providing this authorization unless the provision of health care is solely for the purpose of creating protected health information for disclosure to a third party.

    * Once this information is released, the receiver may further release it and it may no longer be protected information.

    * I may have a copy of this signed authorization.