I authorize EM•POWER with Moxi to exchange information and obtain necessary documents pertaining to my embryo donation with the following parties, including but not limited to medical records, legal contracts/consents/clearances, third party records (such as egg/sperm donor profiles) with the following parties:

Documents to be shared with and by:

Name of organization: EM•POWER with Moxi
Contact: Gina Davis
Address: PO Box 82641 Portland, OR 97282
Phone: 503-837-1810
Fax: 415-970-5021
Email: gina@empowerwithmoxi.com

Electronic documents requested. Please alert us if you send documents by mail.

NOTICE:
Organizations such as physicians, hospitals and health plans are required by law to keep your health information confidential. If you have authorized the disclosure of your health information to someone who is not legally required to keep it confidential, it may no longer be protected by state or federal confidentiality laws.

YOUR RIGHTS:
This authorization to release health information is voluntary. Treatment, payment, enrollment or eligibility for benefits may not be conditioned on signing this authorization except in the following cases: (1) to conduct research-related treatment, (2) to obtain information in connection with eligibility or enrollment in a health plan, (3) to determine an entity’s obligation to pay a claim, or (4) to create health information to provide to a third party.

This authorization may be revoked at any time. The revocation must be in writing and signed by you or your patient representative. The revocation will take effect when we receive it. You are entitled to receive a copy of this authorization.

Duration: This authorization is valid for one year from the date of the signing unless revoked in writing by the undersigned within one year.

Embryo Donor #1 Signature: BY SIGNING HERE, I AM AGREEING THAT I HAVE READ, UNDERSTAND AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.