Authorization Release of Medical Information

Today's Date:

Date

I hereby authorize the use or disclosure of information from the medical record of:

Name:

First NameLast Name

Date of Birth:

Date

Email:

example@example.com

Last 4 of SSN:

I authorize the following Physician/Hospital to disclose the above named individual’s health information:

Name of Physician and/or Name of Clinic

Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number:

Area CodePhone Number

Fax Number:

Area CodePhone Number

APPROXIMATE DATES OF SERVICE:

Type of Information to Be Released: (For the purpose of Screening, Testing, and Treatment for aforementioned patient to be a Gestational Carrier) Problem List Progress Notes Laboratory Results - all pregnancies History/Physical Medications Genetic Testing, if applicable Imaging Reports Other Diagnostic Reports

Release Information to the Following:

Beth Moszkowicz

Executive Director, Paying It Forward Surrogacy, LLC

3623 Hyland Frost
San Antonio, Texas 78257

beth@payingitforwardsurrogacy.com

Phone: 608-345-6270

Fax: 214-753-4584

Faxing of records is preferred.

I understand that the information in my health record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services, and treatment for alcohol and drug abuse. I understand that the information released is for the specific purpose stated above. Any other use of this information without the written consent of the patient is prohibited. I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing and present my written revocation to the individual or organization releasing information. Unless otherwise revoked, this authorization will expire on the above date, event or condition. If I fail to specify an expiration date, event or condition, this authorization will expire in six months. I understand that I may inspect or copy the information to be used or disclosed, as provided in CFR 164.524. I understand that any disclosure of information carries with it the potential for an unauthorized redisclosure and the information may not be protected by federal confidentiality rules. If I have questions about disclosure of my health information, I can contact Paying It Forward Surrogacy, LLC.

Signature

Email

example@example.com

Authorization to Release Medical Information