Release of Medical Information Form

  • If you would like us to fax the selected record(s), please provide the fax #
  • If you would like us to email the selected record(s), please provide the email address. NOTE: UALR 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.
  • I hereby release the University of Arkansas at Little Rock and the UALR 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 authorized above. I understand that once this information has been disclosed to a party other than a health care provider or health plan covered by the state and federal privacy regulations, the information may be re-disclosed and is no longer protected by the state and federal privacy regulations.
    I acknowledge that this consent will be valid for 90 days from the date of my signature unless otherwise specified below
  • Date Format: MM slash DD slash YYYY
    If you would like this consent to expire before or after the standard time of 90 days from your signature, please provide your chosen date of expiration.
    I understand that I can withdraw this consent for release of information at any time prior to the expiration date chosen, except to the extent that action has already been taken in reliance hereon. I further understand that UALR Health Services may refuse to release my records where it is determined that such release may be detrimental to my physical or mental health. Should I wish to revoke my consent for the release of information, or if I disagree with a refusal to release records, I should do so in writing as set forth in the UALR Health Services Notice of Privacy Practices.
  • Electronic signatures are legally binding and equivalent to handwritten signatures
  • Date Format: MM slash DD slash YYYY
    Date of Signature