Pacific In Vitro Fertilization Institute Tel 808.946.2226 Fax 808.943.1563 ari Morton, M.. (Cel Dominguez, MO. “Tomas TF Huang, Ph, HCLO, ELD AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS FF PACIFIC IN VITRO FERTILIZATION INSTITUTE To: Pace n Vt Frtzation stu bate oe oe ee ae iPr Patan ame) ‘herby authori the use or escosieof my invivaly identifiable heath informations desrbed below. | understand ‘hat this authorzatin i vluntary. This information i being closed forthe purpseof continue health care and infertity dagnoss and veaument. request copes ofthe fllowing documents and actual nell reports sen to Name: ax Phone {6¥N operative and pathol reports Blood tet resus (FSH, Ut rlat, Progesterone, stall) Fertity maceation and rextment, HW screening other: ona understand that the ogalzaton to rece the Information nt helt plan or heath ate provider, ‘the released infrnaton may no longer be protected by federal pracy regulations ovat "understand Pate In Vito Fertizatin institute ts employees, officers an physlns are released from ‘any legal respons or lab fr releasing the requested information as authored (ouat____[ ]1do9e 1 do et authorize the release document wth information abut: ‘* HlVer ADS infection or venereal vee; ‘+ Treamnent for aleohol and/or dug abuse and/or 4 Merial healt or payhitie services. "understand that his authorization wl exite 12 months rom the date of execution. "understand that may revoke ths authorization at any imeby notifying his acy in wrtng. 10 Understand that revoking thi authorization wil not sply ony infomation elated by tia belore ‘hey recive the revoeaton Print Paint Name: Patient Signature: ate ‘onstaze* fn ate St.) naan can” moBpetenOCOM