AUTHORIZATION FOR CHARLOTTE H. DANCIU, P.A. TO DISCLOSE PROTECTED HEALTH INFORMATION

I authorize Charlotte H. Danciu, P.A., to disclose the above-named individual’s health information as described below.

I understand that this information may include, when applicable, information relating to sexually transmitted disease, Human Immunodeficiency Virus (HIV infection, Acquired Immune Deficiency Syndrome or AIDS Related Complex) and any other communicable disease. It may also include information about behavioral or mental health services, and referral or treatment for alcohol and drug abuse (as permitted by 42 CFR Part 2

This information may be disclosed to and used by the following person or organization.

Attorney(s) for adoptive parent(s) Agency for adoptive parent(s) Interstate Compact on the Placement of Children, as necessary Other:

Adoptive parent(s) Court in connection with adoption, as necessary

This disclosure and use is for the following purpose: Adoption matter

I understand that I have the 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 Law Offices of Charlotte H. Danciu, P.A. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. Unless otherwise revoked, this authorization will expire one year from the signature date.

I understand that authorizing the disclosure of this health information is voluntary. I also understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment, payment for services, or eligibility for benefits.

Signature of individual or Legal Representative

Relationship of Representative:

1. 2.The following individual or organization is authorized to make the disclosure:

I authorize the use or disclosure of the above named individual’s health information as described below:

I understand that the information may include information relating to sexually transmitted disease, acquired

This information may be disclosed to and used by the following individual or organization:

The Law Offices of Charlotte H. Danciu, P.A. 202 N. Swinton Avenue, Delray Beach, Florida 33444

I understand I have the right to revoke this authorization for my child at any time. I understand if I revoke

7. authorization. I need not sign this form in order to assure treatment. I understand I may inspect or copy the information to be used or disclosed, as provided CFR 164.524. I understand any disclosure of information carries with it the potential for an unauthorized re-disclosure and the information may not be protected by federal confidentiality rules. If I have questions about disclosure of my health information, I can contact an attorney or The Law Offices of Charlotte H. Danciu, P.A.

I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this

Printed Name and Relationship of Representative

NOTE: This form must be submitted by the agency identified at the bottom of this page. The applicant may NOT SUBMIT THIS FORM DIRECTLY to the Department of Children & Families.

LIST ALL minor household members on this form. Do not include ANY adult household members or foster care children.

(Please Print Clearly – Last Name, First, Middle)

(Include city, state, and Zip Code)

Dates at Address (Include city, state, and Zip Code) By signing this form, I, as an applicant for adoption, authorize a search for reports of abuse, neglect or abandonment investigated in which my name appears and there were “verified findings” of maltreatment of a child(ren) and I am listed as the “Caregiver Responsible”. I further understand that the central abuse hotline search is only one part of the preliminary report to the court for adoption. I understand I will be given the opportunity to discuss the findings of the report(s This consent is valid solely for the requesting agency/facility listed below on this form. (Chapter 39, F.S.)

ALL ADULT (18 & UP) HOUSEHOLD MEMBERS MUST SUBMIT A SEPARATE REQUEST FORM

Please use another request form for additional household members

Printed Name and Signature of Requesting Facility/Agency Representative

Please return to DCF via email: Attention: Private Adoptions

email: hqw.bgs.adoptions@myflfamilies.com

A basis for planning my care and treatment, A means of communication among the many health professionals who contribute to my care, A source of information ~or applying my diagnosis and surgical information to my bill, A means by which a thlrd-partY payer can verify that services billed were actually provided, and A tool for routine healthcare operations such as assessing quality. and reviewing the competence of healthcare professionals.

I understand and have been provided with a Notice of Privacy Practices that provides a more complete description of information uses and disclosures. I understand that I have ttie following rights and privileges:

The right to review the notice prior to signing this consent, The right to object to the use of my health information for directory purposes, and The right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or healthcare operations.

I understand that Fertility & IVF Center of Miami Is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has alreaay take action In reliance thereon. I also understand that by refusing to sign this consent or revoking this consent this organization may refuse to treat me as permitted by Sacfion 164.506 of the Coda of Federal Regulations.

I further understand that Fertility & IVF Center of Miami reserves the right to change their notice and practices and prior to implementation, in accordance with Section 164.520 of the Code of Federal Regulations. Should Fertility & IVF Center of Miami change their notice, they will make a copy of the revision available.

I hereby authorize the Fertility & JVF Center of Miami to disclose, without restrictions, any and all my health information to:

ANY POTENTIAi:. EGG RECIPIENT, INTENDED PARENT, AGENCY, AND ANY HEALTHCARE

PROVIDER INVOLVED IN MY POST, PRESENT OR FUTURE CARE.

I wish to have the following restrictions to the use or disclosure CJf my health Information:

I understand that as part of this organization's treatment, payment, or health care operations, It may become necessary to disclose my protected health Information to another entity, and I consent to such disclosure for these permitted uses, including disclosures

I fully understand and accept/ decline the terms of this consent

Consent received by~---,.c-~~~-~on, Consent refused by patient, an.d treatment refused as permitted. Consent not signed due to language barrier.

I (we) hereby authorize the release of any information requested by CHARLOTTE DANCIU, P.A. to be utilized in determining my suitability to be an adoptive parent. I (we) hereby grant permission to CHARLOTTE DANCIU, P.A. to obtain information from local, state, or federal law enforcement agencies to help determine my (our) suitability to serve as egg donor/gestational surrogate/traditional surrogate. I (we) understand, however, that a history of arrest reported by any of these agencies will not necessarily prohibit my (our) participation in the adoption program.

Pursuant to Florida Statute 415.51(4), I (we) hereby authorize CHARLOTTE DANCIU, P.A. to make inquiry of the Child Abuse Registry and the Florida Department of Law Enforcement in regard to the existence of any indicated report of abuse or neglect, and the results of any investigation and any criminal records pursuant to hereto. I (we) understand that the results of this inquiry will he held confidential by CHARLOTTE DANCIU, P.A.

A CHECK OR MONEY ORDER MUST BE SUBMITTED ALONG WITH THIS REQUEST MADE PAYABLE TO THE FLORIDA DEPARTMENT OF LAW ENFORCEMENT. THE FEE FOR SAME IS $25.00 PER PERSON.