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Waiver of Confidentiality for the Adoptee
To Whom It May Concern:
I, (your name) was born on January 1, 1946 in Pittsburgh, Pennsylvania, County of Allegheny and adopted by (list your adoptive parent’s names).
I hereby authorize (name of agency or court) to release any and all information about be to either of my natural parents or other relatives that I have by birth. I waive my rights to confidentially in regard to my adoption and records of the action.
I would like to have this waiver of confidentiality placed into my adoption files as a permanent part of the record
Signature: (sign in front of a notary and give your complete address.)
If you should move make sure you update the waiver of confidentiality
Send a "Waiver of Confidentiality" (see attachment) to:
a. The Court where adoption was finalized. (example: Orphans Court of Allegheny County)
b. The agency or independent person (attorney, doctor, or clergy) who handled the placement.
c. Bureau of Vital Statistics: In PA. Send to:
Commonwealth of Pennsylvania
Department of Health
Bureau of Vital Statistics
P.O. Box 1528
New Castle, PA 16103 - 1528
You can send you waiver of confidentiality along with a letter asking if your biological parents have submitted a "Biological Parent Registration Form." The fee for this is $4.00
The Waiver of Confidentiality will give legal notice to the agency, court and state that you want them to share with your biological parents your identity and other information if they request it.
Biological parents are required to submit a "Biological parent registration form" to the Department of Vital Statistics if they wish to have a waiver placed in the adoption file. When you send your waiver of confidentiality, ask if either of your biological parents have filed this registration form.
The Waiver of Confidentiality will give legal notice to the agency, court and state that you want them to share with your biological parents your identity and other information if they request it.
Biological parents are required to submit a "Biological parent registration form" to the Department of Vital Statistics if they wish to have a waiver placed in the adoption file. When you send your waiver of confidentiality, ask if either of your biological parents have filed this registration form.
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Waiver of Confidentiality for Birth Parents
TO WHOM IT MAY CONCERN:
I, (Present Identity), a.k.a. (name used to sign consent) of Address, including city, county, & state) do state that:
I did on (day, month, year) at (hospital of birth) (place of birth, address) give birth to a (male/female) which I named (or did not name) (first, middle, surname). That I, under the name of __________________________, consented to relinquish, by signature to: (name of placing agency/intermediary) of (city, county, state) and did grant the legal right to said parties to place my child, (name of child) for adoption.
I (present name), hereby state that I waive ALL RIGHTS OF CONFIDENTIALITY extended to self under past and present identity, granted to me by the Statues of the State of (name of State), known court of jurisdiction thereof, and the (placing agency) or person (intermediary) and to my child (name at birth) in his/her present adoptive identity. That access to these confidential records is to include all court and placing agency records, all social-biological-medical history and heritage, pertaining to self, together with my past and present identity and the identity of my child by birth. This waiver of confidentiality and right to privacy is extended solely to my child and none other. Permission is granted to the holder of this waiver to furnish a photocopy of this transcript to my child, and this to be regarded as full consent, for the release of the original certificate of birth by full transcript.
(date)____________________________________
(Month, day, year)
(Signature, using present identity)
___________________________________
(Signature, using name signed on consent to surrender)
(Must be Notarized)
Subscribed and sworn to before me on this __________day of________________ 19______.
______________________________
(Signature of Notary)
Send copy to:
Agency and/or private intermediary
Court where adoption was finalized
*NOTE: In order to register with PA. Vital Statistics you must write and request the "Biological Parent's Registration Form. Send your request to:
Dept of Vital Statistics
P.O. Box 1528
New Castle, PA 16103-1528
The form must be notarized before it is returned to Vital Statistics
The Waiver of Confidentiality will give legal notice to the agency, court and state that you want them to share with the adoptee and/or adoptive parents your identity and other information if they request it.
Biological parents are required to submit a "Biological parent registration form" to the Department of Vital Statistics if they wish to have a waiver placed in the adoption file.
You can also include a letter to your child, to be placed in the adoption files. For the correct address, call or write the Court House in the County in which the Adoption was finalized and ask to whom adoption related inquires should be addressed.
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HOSPITAL RECORDS AND
MEDICAL RELEASE FORM FOR ADOPTEES
A new born is considered a patient, so separate medical files are created for both the mother and the child. If you know your name at birth you may be able to obtain your medical records. These records, in addition to the mother's name and address at the time may show next-of-kin, mother's birth date, social security number, and other background information. DO NOT MENTION ADOPTION!!! Sample letter:
Name of Hospital
Medical Records Dept.
Street
City, State, Zip
To Whom It May Concern:
I authorize and request the (name of hospital) to furnish to myself a copy of all information concerning my admission, full medical record of delivery, statistics at birth, footprints if taken, nursery record, physical examinations, discharge records. The following information will assist you in locating my records:
Patient: (full name at birth)
Date of Birth:
Mother's Name:
Father's Name:
Signatures:
Name at birth
Current name (use your first name at birth and your current last name)
Address
City, State, Zip
If the hospital no longer exists, call the Department of Hospital Records in Harrisburg (717) 783-1288, to find out if and where those records are available.
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HOSPITAL RECORDS and
MEDICAL RELEASE FORM FOR BIRTHPARENTS
These records will not help a birthparent to locate a surrendered child but by obtaining the birth records you might receive a copy of the child’s birth registration and a copy of the foot prints. This will validate your birth experience.
If the hospital is reluctant to provide the records to you, then ask your personal physician to request them.
Send for your hospital admission records for the time of the birth, for yourself and for your child. You have a right to copies of all medical records for yourself. A medical release request can be hand written or typed.
Example:
Date
Name of Hospital
Medical Records Department
Address
City, State, Zip code
I authorize and request the (Name of Hospital) and the physicians who attended me while I was a patient in said hospital from (date to date) to furnish to myself a copy of all information concerning my case history and treatment and also a copy of the medical records of the child, (name at birth), who was born to me on (date).
(Name at time of admission)
Signed
Current Name
Address
________________________
Witness
The court order to seal the court records and the birth certificate does not order the hospital records sealed -- nor is adoption sealing retroactive. The birth parent was the legal guardian at the time of birth and until signing relinquishment papers.
If the hospital no longer exists, call the Department of Hospital Records in Harrisburg (717) 783-1288, to find out if and where those records are available.
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QUESTIONS FOR ADOPTEES TO ASK
ABOUT PLACEMENT:
1. Placing agency
2. Social worker
3. Name of Adoptee
4. Personal history requested: born - date; place; adoptive parents; court of jurisdiction; city of; state of; county of
5. Petition number; filed; attorney of record; address
6. Decree granted
7. Adopted placed with petitioners by this placing agency - month; day; year
8. Surrender signed by birthmother or other guardian to this agency; date
9. Consent to this adoption by; address; date
10. Present social worker assigned to this case
ABOUT BIRTH MOTHER'S HISTORY:
1. Mother's given name
2. Mother's age at birth of adoptee; Mother's date of birth; place of birth; if born other that U.S.; citizenship status
3. This pregnancy: Full term? Hours in labor; Delivery - Normal? Surgical? Known medical history of mother; Known medical history of infant in hospital and while under the agency's care
4. Infant: given name; date of birth; hour of birth; weight at birth; length; general physical and medical condition at birth; breast fed or formula
5. Mother's date of admission to hospital
6. Mother's date of discharge from hospital
7. Infant discharged with mother? date; to other than mother?; to whom?
8. Mother's full physical description
9. Mother's stated religion (be exact); was this child baptized prior to placement with adoptive parents; under what condition; place and date; by whom; in what faith?
10. Order of birth to mother, this child
11. Mother's marital status at birth of this child; single, married, separated, divorced or widowed; husband's name; is husband the father to this child
12. Mother's extraction by birth
13. Mother's top educational level -- grade school, where? High school, where? College, where? Other, where?
14. Mother's know occupations; how many years
15. Mother's usual state of residence
16. Did mother have siblings? show sex, given names, ages at this birth.
17. Did mother have special interests or talents
18. Mother's stated reason for surrendering this child to adoption
19. Has mother made any contact with this agency since the time of placement in respect to this child - explain
20. Exact age of this child when surrendered to agency
21. Was this child in foster home(s); from -- to; how many
22. Did birth mother supply this agency with infancy pictures of adoptee; self or other next of kin; if so, may adoptee have same.
ABOUT BIRTH FATHER'S HISTORY:
1. Father's given name
2. Father's place and date of birth
3. Father's extraction; citizen by birth; by naturalization
4. Educational level
5. Stated religion
6. Full physical description
7. Father's marital status
8. Did father have siblings; show sex, given names, ages
9. Father's known occupations
10. Special talents or interests
11. Usual state of residency
12. Was father advised of mother's pregnancy; how; his reaction; supportive to birth mother; acknowledge his paternity of child; how
13. Child was conceived through established relationship? or brief affair - explain
ABOUT GRANDPARENTS:
1. Living or deceased at birth of this child; age
2. Did they have knowledge of this child
3. Personal feelings in respect to the birth of this child
4. If deceased at birth of this child; age at death; cause of death; year of death
5. State of residence; at death
6. Known occupations
7. Known medical history
8. Names
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