Special Angels - Medical Release Authorization

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Authorization For Release Of Medical Information:

To any physician, medical facility, psychiatrist, psychologist, adoption agency, federal, state, county or city agency, attorney or layperson – this is a request for mock discharge paperwork and an authorization. I, the undersigned, authorize the release of medical records and information to:

Special Angels Adoption
135 E Huron St. Suite 106
Jackson, OH 45640
Phone 256-452-9504
Fax: 1-740-422-1675

You may release any and all medical information, health information, psychological, psychiatric, birth certificated, and/or miscellaneous records including a picture pertaining to me or any child of mine who is being considered for adoption. You are further authorized to freely verbally discuss any interaction you may have had or may have with me in relation to this adoption or my past medical history. You have my authorization to copy or receive copies of any and all records or documents pertaining to me and/or my child. This information may be used in control of the child (born or unborn) being considered for an adoption.

Physician Name: *

Physician Phone: *

Physician Fax: *

Physician Address: *

Has the child being considered for adoption been born yet? *

Child's Name At Birth: *

Birth Date of Child (MM/DD/YYYY): *

Expected Due Date of Child (MM/DD/YYYY): *

In the event of the placement of my child for adoption, I, the undersigned, being the parent of this child, authorize and empower the adoptive parents and/or agency to whom I release the child to make any decisions or provisions concerning medical and surgical care for said child, including anesthesia, which may be deemed necessary or advisable by any licensed physician during the period following the filing of a petition for adoption with the court and throughout the pending adoption process.

Date: * +

Birth Parent FULL Name: *

Birth Parent's Date of Birth (MM/DD/YYYY) *

Birth Parent Signature: *

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