Release of Medical Information Form

You must scan a form of identification to before any information will be released.(Required)
Patient Name(Required)
Purpose of Disclosure(Required)
To whom should Health Services release the information to?(Required)
UA Little Rock Health Services is not responsible for confidentiality of your record after you have given written consent to send it via fax.
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.
I understand that I may revoke this Authorization at anytime by providing a written notice of revocation to 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.
Electronic signatures are legally binding and equivalent to handwritten signatures
MM slash DD slash YYYY
Date of Signature