Free Medical Record Release Form - Hawaii

State Department of Health Office of Health Status Monitoring

MEDICAL RECORD RELEASE FORM To Whom It May Concern: Re: Birthname of Child and Birthdate I authorize release of the medical information given in the attached "Medical Information Form" pertaining to me. The information is prepared under Section 578-14.5, Hawaii Revised Statutes for the purpose of perpetuating medical information on natural parents of an adopted minor child and is to be released to or for the benefit of the adopted child. Name of Natural Parent (Print) Signature

(Print using black ink or use typewriter)