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.