Fillable Arkansas HIPAA Privacy Authorization Form

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Arkansas HIPAA Privacy Authorization Form

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The Arkansas HIPAA Privacy Authorization Form form is 2 pages long and contains:

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  • 8 check-boxes
  • 8 other fields

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Arkansas HIPAA Privacy Authorization Form
**Authorization for Use or Disclosure of Protected Health Information
(Required by the Health Insurance Portability and Accountability Act, 45 C.F.R.
Parts 160 and 164)**
**1.$Authorization**$
I$authorize$________________________________________$(healthcare$provider)$to$use$
and$disclose$the$protected$health$information$described$below$to$
______________________________________________$(individual$seeking$the$information).$
**2.$Effective$Period**$
This$authorization$for$release$of$information$covers$the$period$of$healthcare$
from:$
a. □ ______________ to ______________.
**OR**
b. □ all past, present, and future periods.
**3.$Extent$of$Authorization**$
a.$□$I$authorize$the$release$of$my$complete$health$record$(including$records$
relating$to$mental$healthcare,$communicable$diseases,$HIV$or$AIDS,$and$treatment$of$
alcohol$or$drug$abuse).$$
**OR**
b.$□$I$authorize$the$release$of$my$complete$health$record$with$the$exception$
of$the$following$information:$$
$□$Mental$health$records$$$
$□$Communicable$diseases$(including$HIV$and$AIDS)$$$
$□$Alcohol/drug$abuse$treatment$$
$□$Other$(please$specify):$_______________________________________________$$
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4.$This$medical$information$may$be$used$by$the$person$I$authorize$to$receive$
this$information$for$medical$treatment$or$consultation,$billing$or$claims$payment,$or$
other$purposes$as$I$may$direct.$$
5.$This$authorization$shall$be$in$force$and$effect$until$___________________$(date$
or$event),$at$which$time$this$authorization$expires.$
6.$I$understand$that$I$have$the$right$to$revoke$this$authorization,$in$writing,$
at$any$time.$I$understand$that$a$revocation$is$not$effective$to$the$extent$that$any$
person$or$entity$has$already$acted$in$reliance$on$my$authorization$or$if$my$
authorization$was$obtained$as$a$condition$of$obtaining$insurance$coverage$and$the$
insurer$has$a$legal$right$to$contest$a$claim.$$
7.$I$understand$that$my$treatment,$payment,$enrollment,$or$eligibility$for$
benefits$will$not$be$conditioned$on$whether$I$sign$this$authorization.$$
8.$I$understand$that$information$used$or$disclosed$pursuant$to$this$
authorization$may$be$disclosed$by$the$recipient$and$may$no$longer$be$protected$by$
federal$or$state$law.$
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Arkansas HIPAA Privacy Authorization Form

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Completed 15 March 2021

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