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Medical Records Release Form

Your application has been completed 95%
      • Please allow us 3-5 business days to review your submission.
      • Meanwhile, please complete the following authorization to finalize your application.

Authorization to Release Medical Records – Office Use

Patient's Full Name
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Do you have a maiden name?
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Date of Birth
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In Pursuant to the Health Insurance Portability and Accountability Act (HIPPA) I hereby authorize the release of my records. I will assume the total responsibility of my copied medical records.
NOTE: We need the information of your OBGyn Dr and delivery hospitals for all your children. From the youngest to the oldest.
What is the total number of your children?
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Have you been a surrogate before?
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Information for My 1st Child (oldest)

I authorize the following provider :
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Physician's Name
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Clinic Address
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Phone Number:
Field is required!
Fax Number:
Field is required!
Delivery Hospital:
Field is required!
Hospital Address:
Field is required!
Phone Number:
Field is required!
Fax Number:
Field is required!

Information for My 2nd Child

Did you use the same OB doctor and delivery hospital for this child?
Field is required!
I authorize the following provider :
Field is required!
Physician's Name
Field is required!
Clinic Address
Field is required!
Phone Number:
Field is required!
Fax Number:
Field is required!
Delivery Hospital:
Field is required!
Hospital Address:
Field is required!
Phone Number:
Field is required!
Fax Number:
Field is required!

Information for My 3rd Child

Did you use the same OB doctor and delivery hospital for this child?
Field is required!
I authorize the following provider :
Field is required!
Physician's Name
Field is required!
Clinic Address
Field is required!
Phone Number:
Field is required!
Fax Number:
Field is required!
Delivery Hospital:
Field is required!
Hospital Address:
Field is required!
Phone Number:
Field is required!
Fax Number:
Field is required!

Information for My 4th Child

Did you use the same OB doctor and delivery hospital for this child?
Field is required!
I authorize the following provider :
Field is required!
Physician's Name
Field is required!
Clinic Address
Field is required!
Phone Number:
Field is required!
Fax Number:
Field is required!
Delivery Hospital:
Field is required!
Hospital Address:
Field is required!
Phone Number:
Field is required!
Fax Number:
Field is required!

Information for My 5th Child

Did you use the same OB doctor and delivery hospital for this child?
Field is required!
I authorize the following provider :
Field is required!
Physician's Name
Field is required!
Clinic Address
Field is required!
Phone Number:
Field is required!
Fax Number:
Field is required!
Delivery Hospital:
Field is required!
Hospital Address:
Field is required!
Phone Number:
Field is required!
Fax Number:
Field is required!

Information for My 6th Child

Did you use the same OB doctor and delivery hospital for this child?
Field is required!
I authorize the following provider :
Field is required!
Physician's Name
Field is required!
Clinic Address
Field is required!
Phone Number:
Field is required!
Fax Number:
Field is required!
Delivery Hospital:
Field is required!
Hospital Address:
Field is required!
Phone Number:
Field is required!
Fax Number:
Field is required!

Information for My IVF clinic

Only applicable if you were a surrogate before.
I authorize the following provider :
Field is required!
Physician's Name
Field is required!
Clinic Address
Field is required!
Phone Number:
Field is required!
Fax Number:
Field is required!

to disclose the following protected health information:

 Time Frame: All the time available.
 Pregnancy related medical records(Pregnancy Office visits, Hospital delivery and discharge records , Lab results)

 Sensitive information including but not limited to: 1) HIV/AIDS, communicable diseases; 2) Drug/alcohol treatment/evaluation 3O Mental health treatment/evaluation 4) Genetic testing
The medical records should be either faxed or mailed to the recipient below:
Attn: FindTheSurrogate LLC

By Mailing: 99 Serene Ct, Danville CA94526

By Fax: 925 800 3460

By Email: info@findthesurrogate.com
I hereby state that I hold the right to revoke this authorization and I am aware that the records may be re-disclosed and no longer be protected. This authorization will expire in 90 days from dated.
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Date:
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