Form 200 "Accreditation Organization Release of Information Consent" - Arkansas

What Is Form 200?

This is a legal form that was released by the Arkansas Department of Human Services - a government authority operating within Arkansas. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • The latest edition provided by the Arkansas Department of Human Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form 200 by clicking the link below or browse more documents and templates provided by the Arkansas Department of Human Services.

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Download Form 200 "Accreditation Organization Release of Information Consent" - Arkansas

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ARKANSAS DEPARTMENT OF HUMAN SERVICES
Accreditation Organization Release of Information Consent
I, __________________________, hereby consent to the exchange of information between
CEO (or equivalent)
_
and
Accrediting Agency
The Arkansas Department of Human Services for the specific purpose of obtaining or sharing information
relevant to Behavioral Health Agency Certification.
I consent to information regarding my agency’s national accreditation or state certifications being
released by facsimile (FAX) __________ Yes ___________ No.
I understand that the information I authorize for release may include sensitive information. I understand
that a facsimile of this consent is considered as valid as if it were the original.
Signature of CEO (or equivalent)
Date
Signature of Witness
Date
DHS Behavioral Health Agency Accreditation Organization Release of Information Consent – Form 200
Effective July 1, 2017
Page 1 of 1
ARKANSAS DEPARTMENT OF HUMAN SERVICES
Accreditation Organization Release of Information Consent
I, __________________________, hereby consent to the exchange of information between
CEO (or equivalent)
_
and
Accrediting Agency
The Arkansas Department of Human Services for the specific purpose of obtaining or sharing information
relevant to Behavioral Health Agency Certification.
I consent to information regarding my agency’s national accreditation or state certifications being
released by facsimile (FAX) __________ Yes ___________ No.
I understand that the information I authorize for release may include sensitive information. I understand
that a facsimile of this consent is considered as valid as if it were the original.
Signature of CEO (or equivalent)
Date
Signature of Witness
Date
DHS Behavioral Health Agency Accreditation Organization Release of Information Consent – Form 200
Effective July 1, 2017
Page 1 of 1