Arkansas Cardiology: Arkansas' Leader in Cardiovascular Care

Arkansas Cardiology For Use/Disclosure of Health Information Form

First Name:         Middle Initial:         Last Name:

Address Line 1:     Apt/Suite/Unit:

Address Line 2:

City:     State:         Zip:

E-Mail:

Home Phone:       Work Phone:       Mobile Phone:

Social Security Number:

Date of Birth

This authorization permits the above provider to disclose the following medical records:

Persons to whom my healthcare provider can disclose my health information to:

All of my health information that the provider has in his or her posession, including information relating to medical history, mental or physical condition and any treatment received by me.
All of my health information described above except for the following items:

Only the following records or types of health information:

Term: This authorization will remain in effect:
From the date of this authorization until:
Until the provider fulfills this request.
Until the following event occurs:

Refusal to sign/right to revoke: I understand that I may refuse to sign or may revoke (at any time) this authorization for any reason and that such refusal or revocation will not affect the commencement, continuation, or quality or my treatment by my healthcare provider.

Expiration: I understand that that this authorization will remain in effect until the term of this authorization expires or I provide a written notice of revocation to my healthcare provider's Privacy Office at the address listed below. A copy of this authorization may be utilized with the same effectiveness as the original or electronic copy.

Patient Signature (Type Full Name)		Date
Person/s authorized to sign for patient (Type Full Name)		Date
(Relationship to the patient)
If other, please list here:
Signature of Witness (Type Full Name)		Date

By checking this box the patient has agreed that they have received a copy of our payment policy and agrees to comply fully with its terms.
By checking this box the patient has agreed that they have received a copy of our HIPAA compliance form.

I authorize the release of medical information necessary to process all medical insurance claims. I also authorize payments of medical benefits to Arkansas Cardiology. I am acknowledging that Arkansas Cardiology has provided me with a copy of their privacy notice. I acknowledge that by submitting this form and entering the digital key below that I fully agree to all terms, signatures and releases above.

Patient Signature (Type Full Name)

Date

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Arkansas Cardiology West 9501 Lile Drive Suite 600 Little Rock, Arkansas 72205 PH:501-227-7596 Fax:501-227-7787
Arkansas Cardiology North 3343 Springhill Drive Suite 1035 North Little ROck, Arkansas 72117 PH:501-975-7676 Fax:501-975-0653