Date of birth:
TO: ANY PHYSICIAN, MEDICAL FACILITY, PSYCHIATRIST, PSYCHOLOGIST, ADOPTION AGENCY, FEDERAL, STATE, COUNTY OR CITY AGENCY OR ATTORNEY.
You are hereby authorized to release to the following agency:
Any and all psychological, psychiatric, health information or birth certificate record pertaining to me or any child of mine which is now, or in the future may be, under your care and are further authorized to verbally discuss any interaction you have had or may have with me.
It is hereby expressly authorized to copy or receive copies of any records or documents pertaining to me or the information specified above. This information may be used in connection with any proceeding concerning the adoption, guardianship, custody and control of my child.
You are also authorized to release 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.
If requested, I authorize Medicaid to release information about me or my children to A Guardian Angel Adoptions, LLC. I authorize Medicaid to provide them my Medicaid number and any other information about my case. I understand that if I apply for Medicaid in Utah, my benefits in another state will be cancelled.
I authorize the OB/GYN, RN or ultrasound technician to tell A Guardian Angel Adoptions, LLC the gender of my unborn child if requested, even if I choose not to know myself.
I also authorize any other adoption agency, counselor, attorney or other professional who is contracted by A Guardian Angel Adoptions, LLC to release information about me, my child(ren), or this adoption to A Guardian Angel Adoptions, LLC. In addition, I authorize A Guardian Angel Adoptions, LLC to release information about me to other adoption agencies if I have contacted them for assistance.
A Guardian Angel Adoptions, LLC, requires all birth parents receiving adoption services be tested for drug use, and that drug test results be reported directly to the agency.
I/we hereby give consent to be tested for drug use. I/we also agree
that the results of such test be released to A Guardian Angel Adoptions, LLC.
Anyone living in housing provided by A Guardian Angel Adoptions, LLC must agree to remain free of all illegal drugs. Anyone found using any illegal drugs must immediately move out. All birth mothers and any adult living with them must agree to have drug tests done at anytime.
I/we have read and agree to abide by the policy concerning illegal drug use in A Guardian Angel Adoptions, LLC housing.
In the interest of obtaining the best care possible for our birth parents and their unborn child/children A Guardian Angel Adoptions, LLC, may require additional medical screenings such as Hepatitis C testing to ensure that appropriate health care is administered and necessary precautions are taken to maximize the potential health and well-being of the birth mother and expected child/children during the pregnancy and delivery of the child. Where necessary, A Guardian Angel Adoptions, LLC, may arrange additional health screenings for Hepatitis C, HIV or other conditions, the results of which must be reported directly to the agency.
I have read, understood and will abide by the policy concerning health conditions screenings for A Guardian Angel Adoptions, LLC.
Medical records may include information related to HIV, communicable disease, alcohol or drug abuse gnosis and treatment. I authorize the release of this type of information to A Guardian Angel Adoptions, LLC.
* 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.