Purpose of disclosure: ADOPTION

I understand that the information used or disclosed may be subject to disclosure by the person(s) or class of person(s) receiving it and no longer protected by the federal privacy regulations. I understand that my confidential information may be read by the prospective adoptive family prior to adoptive placement and subsequently released to the adoptive family upon an adoptive placement. I understand that I may withdraw this consent at any time as long as the request is made in writing to the above listed medical provider. However, I understand that if I revoke this authorization, it will not have effect on action taken by the above medical provider in reliance on it before my revocation. I also understand that refusal to sign this authorization will not prevent my ability to get treatment, payment, enrollment in a health plan, or eligibility for benefits.