Release of Information

Complete the form below with the information we need to request a release of information from your adoption provider. When you complete this form, you and your adoption provider will recieve an email with the release request as a PDF.

  • I do hereby give permission for those receiving this release to provide the following records related to a our adoption to the organization listed below:

    HeartsConnect
    9673 South 700 East
    Sandy, Utah 84070
    Phone: (801) 563-1000
    Fax: (801) 563-9899

    Adoption Records are for the purpose of Post Adoption Communication.

  • Please deselect any items you do not wish to have disclosed.
  • All information I hereby authorize to be obtained from this agency will be held in strictly confidential and cannot be released by the recipient without my express written consent. I understand that this authorization will remain in effect for 1 (one) year.

    I understand that the information used or disclosed may be subject to disclosure by the person(s) receiving it and no longer protected by the federal pricey regulations.

    I understand that I may withdraw this consent at any time as long as the request is made in writing to the avocet organization. However, I understand that if I revoke this authorization, it will not have effect on action taken by the above service provider in reliance on it before my revocation.
  • We understand that, in some circumstances, it might not be a good idea to have proof of your communication with us in your inbox. So, please let us know your preference below.
  • This field is for validation purposes and should be left unchanged.