Medical Record Request

(STAT)

By signing this form, I authorize you to disclose my protected health information (PHI) to Magic Journeys, LLC (an egg donation and surrogacy agency).

Name(Required)

Email(Required)

Provider Information:(Required)

Provider Phone:(Required)

Provider FAX:(Required)

Patient Name:(Required)

Date of Birth:(Required)

Last 4 Digits of SSN:(Required)

Coverage Period (FROM):(Required)

Coverage Period (TO):(Required)

Authorization Duration: This authorization is valid for one year from the signing date. Release Instructions: Please fax or email my medical records to:

Magic Journeys, LLC Fax: 626-610-7048 Email: MedicalRecords@magicjourneyssurrogacy.com Address: 785 S. Marengo Ave., Unit 1, Pasadena, California 91106

Please release my medical records including: All medical records, including delivery notes, medical history, treatments, OB records, genetic testing, drug information, office visits, labs, x-rays, surgeries, and HIV/AlDS records. Purpose: The purpose of the release is to obtain records related to infertility or gynecological issues. Magic Journeys, LLC will not receive payment from a third party for this information.

I release you from all legal responsibility or liability that may arise from this authorization. l do not have to sign this authorization in order to receive service from Magic Journeys, LLC. In fact, l have the right to refuse to sign this authorization. When my information is used or disclosed pursuant to this authorization, it may be subject to redisclosure by the recipient and may no longer be protected by the federal HIPAA Privacy Rule. l have the right to revoke this authorization in writing except to the extent that the practice has acted in reliance upon this authorization.

A photocopy, fax, or electronic copy of this authorization is as valid as the original.

Patient Name (Please print)(Required)

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