HIPAA Communication Release Form:
Authorization to Collect, Disclose, and Discuss Information
This authorization complies with the Health Insurance Portability and Accountability Act (“HIPAA”)
Email for Data Transmission:
Authorization to Obtain Contracts and Fertility Cycle Related Medical Records
I hereby authorize the Egg Donation & Surrogacy Center, a division of Blissful Fertility, LLC (the “Company”) and its producers, employees and representatives, to email a copy of all of my health information and medical records they have on file related to my egg donation cycle including but not limited to medical records, treatments, stimulation records, legal agreements and contracts, signed consents, and identifying information related to my cycle. I hereby grant permission to the Company above to review, send, and discuss any and all medical or cycle records, match sheets, agency agreements, psychological reports, genetic results, or legal contracts with me through the email provided above. I further understand that these records may be related to physical and mental health conditions, use of alcohol, drugs, and tobacco, drug prescriptions and communicable diseases, including Human Immunodefiniciency Virus (HIV) and AIDS, and may include other personal information about me, my family health, and my Intended Parent(s).
Authorization for Communication and Permission to Verify my Match
I understand and agree that these disclosures, releases, and communications can take place by phone, writing, text, email, fax, or in-person communications. I understand that there are certain risks associated with online or data transmission by facsimile, text, or email and I hereby release and hold Blissful Fertility, LLC and all covered entities listed above harmless and I agree to indemnify them from any and all claims related to this data transfer.
Right to Revoke Release
I may revoke this Authorization in writing at any time, except to the extent that action has been taken in reliance of this Authorization. Written notices should be mailed to Blissful Fertility by certified mail to:
Blissful Fertility, LLC
9465 Wilshire Blvd Ste 300
Beverly Hills, CA 90212.
I understand that any information that is disclosed prior pursuant to this Authorization may be re-disclosed and no longer covered by federal rules governing privacy and confidentiality of health information.
This authorization shall remain in force following the date of my signature below. A copy of this authorization is as valid as the original. I acknowledge that I have received a copy of this authorization.
I hereby understand and agree to the terms of this HIPAA agreement.