MEDICAL INFORMATION DIVULGATION AUTHORIZATION AGREEMENT
Patient Name: _______________________Date of birth: ___/___/____
I hereinafter authorized the employees of ________________________ to report to Reprogenetics Latinoamerica and it personnel, all the information about my health status in order for them to perform the PREIMPLANTATION GENETIC DIAGNOSIS (PGD) of my pregnancy and the born baby.
This authorization is limited to 12 month after the beginning of my IVF cycle.
STARTING ON: ___/___/______ (complete date - dd/mm/yyyy)
Limited information to be shared:
· PGD related information
· Previous pregnancy and infertility history
· Genetic history regarding Karyotype and other tests
· IVF stimulation progress information
· After IVF procedures embryologic records
· Pregnancy test results and embryo replacement
· Pregnancy results and baby borne
· Test results of genetic conception products
· Child information and genetic records if available
This is my legal consent of used of my medical records and information, for the exclusive used of Reprogenetics Latinoamerica and for any and all the associates of Reprogenetics Latinoamerica that must be involved in my PREIMPLANTATIONAL GENETIC DIAGNOSIS (PGD) testing.
I understand that:
I got the legal right to revoke this authorization at any time, that this revocation must be send in writing and presented to the Health Area Manager of the Medical Center ___________________________named at the beginning of this agreement. This revocation takes effect 48 hour after the formal notice to ____________________________, this authorization will automatically ended three month after the baby birth. My special written notice is required to extend the life period of this agreement.
I understand that this voluntary authorization agreement is necessary to proceed with my PGD testing. I understand that on my request I can get a copy of the information that will be transmitted about my medical records.
I understand and agree that my records could and will be inspected by the Peruvian National Health Authorities and any other government surveillance agency.
Patient Signature
Date
Witness name
Witness signature
Date