State Department of Health Office of Health Status Monitoring MEDICAL RECORD RELEASE FORM Date: To Whom It May Concern: Re: (Child's Birthname and Birthdate) I authorize release of: (1) my Medical Records regarding the birth of the above-named child; and (2) the medical information given in the "Medical Information Form" pertaining to me. Pursuant to section 578-14.5 of the Hawai`i Revised Statutes, the medical records and information are for the purpose of perpetuation of medical information on natural parents of the above-named child, and are to be released to or for the benefit of the above-named child. Print Name of Natural Parent: Signature of Natural Parent: (Print using black ink or use typewriter) FC Adm 1/19/16 Reprographics (2/2016) Medical Record Release Form 1F-P-1032 In accordance with the Americans with Disabilities Act, as amended, and other applicable state and federal laws, if you require accommodation for a disability, please contact the ADA Coordinator at the First Circuit Family Court office by telephone at 954-8200, fax 954-8308, or via email at adarequest@courts.hawaii.gov at least ten (10) days prior to your hearing or appointment date. Please call the Family Court Service Center at 954-8290 if you have any questions about forms or procedures. American LegalNet, Inc. www.FormsWorkFlow.com Section 508 Certified