Pact Record Release Authorization And Pregnancy Verification Page 2
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1
2Prenatal medical record release
I, ______________________________________, hereby authorize the release of any and
all information and/or records relating to my care including history, diagnosis, reports,
treatments, labs, or x-rays in your possession while a patient at your facility to Pact: An
Adoption Alliance, the adoptive parents, and the adoptive parents’ physician.
_______________________________________
____________
Patient’s Signature
Date
Child’s Record Release Authorization
I, ___________________________________________________, being the parent of
name of birth parent
_______________________________________ a minor child born on
name of child as it appears on birth certificate
____________________________,
date and time of birth
do hereby authorize the release of any and all of the records relating to the care of said
child, including history, diagnosis, reports, treatments, labs, or x-rays in your possession
while a patient at your facility to Pact: An Adoption Alliance, the adoptive parents, and
the adoptive parents’ physician.
____________________________________
_________________
Parent’s Signature
Date
pact, an adoption alliance
4179 Piedmont Avenue, Suite 101, Oakland, CA 94611
Telephone 510.243.9460
Facsimile 510.243.9970
birth parents 800.750.7590
email
Beth Hall, Director
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