Re:_____________________________ _____-_____-_____ _____________
Name Social Security # Date of Birth
I/We agree that the
following information can be exchanged on an ongoing basis between Full Circle
Adoptions and:
Please fill in the name of the Hospital where you have or will receive prenatal or birth care.
_________________________________________________
Name
_________________________________________________
Address
_________________________________________________
_________________________________________________
Phone number of
health care provider
_________________________________________________
Fax number of health
care provider
The specific
information to be included is all adoption related medical information. This shall include results of any HIV+,
testing and any federally or state protected medical information such as
substance abuse treatment records.
The information may
be released or discussed by telephone.
I have read and
understand the above statement and voluntarily consent to release the above
mentioned information. I understand
that I may revoke this consent at any time except after the information has
already been released. The
authorization extends to the date of a finalization of any pursuant to the
Agency’s services.
I/We release Full
Circle Adoptions, its Board of Directors, and any employees, independent
contractors and staff from all legal responsibility or liability that might
arise from this disclosure.
_____________________________ ____________________
Name(s) Date
Please return to Full
Circle Adoptions and Family Building Center, Inc.,
39 Main Street, Northampton, MA 01060