Date of birth:
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:
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 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.