The Fertility Center of Las Vegas
This form authorizes The Fertility Center of Las Vegas to release protected health information on a patient to another Individual, Company, or Agency.
  • Date Format: MM slash DD slash YYYY
  • *For Egg Donors/Gestational Carriers, please write “Intended Parents” above. No indemnifying information will be released for anonymous egg donors.

  • I understand:

    • This authorization will expire two years after the date of any resulting infant or two years after the pregnancy is terminated.
    • This authorization may be revoked in writing at any time except to the extent that any person has already acted in reliance on my authorization.
    • Treatment or payment for treatment will not be conditioned on my providing this authorization unless the provision of health care is solely for the purpose of creating protected health information for disclosure to third party.
    • The information released in response to this authorization may be re-disclosed by the recipient to other parties.
    • I may have signed a signed copy of this authorization and I have the right to request and receive copies of the collected information*.

    *Medical Records Copying Policy: There will be a .60 cents per-page fee for photocopies of medical records. The fee will be waived for medical records released to a physician’s office, agency and/or legal requests. Medical records will be ready within 5 business days after the date of receipt of the request. Only the person requesting the records may receive them and will be verified by a photo ID.
  • Date Format: MM slash DD slash YYYY