Release of Medical Information Form

You must scan a form of identification to health@ualr.edu before any information will be released.(Required)

I have scanned a copy of my card.

Patient Name(Required)

First Last

Date of Birth(Required)

Phone(Required)

Student ID #(Required)

Purpose of Disclosure(Required)

Which medical records would you like Health Services to release? You must scan a copy of your UA Little Rock ID card to health@ualr.edu. Records will not be released without an ID card. You may request to pick up your records in person. Please bring your ID with you.(Required)

If you chose "lab results" or "other," please provide additional details such as name of lab and date of service if known.

To whom should Health Services release the information to?(Required)

Self (same as patient name)

Other

If you chose "other," please provide information on who we are sending the information to, i.e. the individual's name or a company name.

Method of Delivery (how you want us to send the requested information).(Required)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Fax #

UA Little Rock Health Services is not responsible for confidentiality of your record after you have given written consent to send it via fax.

Enter Email Confirm Email

UA Little Rock email is not encrypted and therefore no guarantee of privacy should be assumed. If you have concerns about potential risks, please choose another method of delivery.

Understanding this Authorization(Required)

I understand that I may revoke this Authorization at anytime by providing a written notice of revocation to health@ualr.edu. Such revocation will not affect any action taken in reliance on this Authorization before receipt of my written revocation. The information used or disclosed pursuant to this Authorization, except information protected by federal regulations about confidentiality of drug and alcohol abuse records, may be subject to redisclose by the recipient and no longer protected by federal privacy regulations or other applicable state or federal laws. I release the University of Arkansas at Little Rock and the office of Health Services, its officers, partners, agents, and employees from any and all liabilities, responsibilities, damages and claims that may arise from the release of information pursuant to this Authorization.

Signed:(Required)

First Last

Electronic signatures are legally binding and equivalent to handwritten signatures

Date(Required)

Date of Signature

About

Services

Release of Medical Information Form

Contact

CampusWell