20 18 HIPAA-COMPLIANT MEDICAL RECORDS RELEASE

• Jurisdiction: Arkansas
• Library: Arkansas Form Book - Complete (2023 Ed.)

20-18 HIPAA-COMPLIANT MEDICAL RECORDS RELEASE

HIPAA-COMPLIANT MEDICAL RECORDS RELEASE

Patient Name: __________ Health Record No.: __________

Date of Birth: __________ SSN: __________

1. I authorize the use or disclosure of the above-named individual's health information as described below:

2. The following individual or organization is authorized to make the disclosure: __________

Address: __________

3. The type and amount of information to be used or disclosed is as follows: (include dates where appropriate)

[ ] problem list
[ ] medication list
[ ] list of allergies
[ ] immunization record
[ ] most recent history and physical
[ ] most recent discharge summary
[ ] laboratory results from (date) ___ to (date) ___
[ ] x-ray and imaging reports from (date) ___

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