ALL ELEMENTS ARE REQUIRED PRIOR TO INFORMATION BEING RELEASED
1. Who is authorized to disclose the information? Arkansas Pediatric Clinic
2. Who is authorized to receive the information?
3. The specific information to be requested or released is:
4. The information is needed for:
5. I understand that if the person or entity that receives the information is not a health care provider or health plan covered by federal privacy regulations, the information described above may be disclosed and no longer protected by these regulations.
6. I understand that Arkansas Pediatric Clinic will be paid for the costs of copying the information to be released.
7. I understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment or payment or my eligibility for benefits. I may inspect or obtain a copy of any information used/disclosed under this authorization.
8. I understand that I may revoke this authorization in writing at any time by delivering a copy of my revocation to Arkansas Pediatric Clinic except to the extent that action has been taken in reliance on this authorization. This authorization expires: One year from date signed.
9. I understand Arkansas Pediatric Clinic will release the requested information only to the entity listed above.
10. I understand that I may receive personal health information via email and I understand that the email containing the requested information is unencrypted.
Your information will be encrypted.
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