"Authorization to Release Information" - Arkansas

Authorization to Release Information is a legal document that was released by the Arkansas Department of Transformation and Shared Services - a government authority operating within Arkansas.

Form Details:

  • Released on October 14, 2019;
  • The latest edition currently provided by the Arkansas Department of Transformation and Shared Services;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Arkansas Department of Transformation and Shared Services.

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Department of Transformation and Shared Services
Governor Asa Hutchinson
Secretary Amy Fecher
Director Chris Howlett
Phone: (501) 682-9656
Toll Free: (877) 815-1017
Fax: (501) 682-1168
http://www.ARBenefits.org
Authorization to Release Information
This form is used to release your protected health information as required by federal and state privacy laws. Your authorization allows
EBD (ARBenefits) to release your protected health information to a person or organization that you choose. You can revoke this
authorization at any time by submitting a request in writing to EBD. Revoking this authorization will not affect any action taken prior to
receipt of your written request.
Member Information: (individual whose information will be released)
Name:
Member ID #:
Date of Birth:
Address:
Telephone #:
I authorize EBD (ARBenefits) to release my protected health information as described below
Recipient: (Person or organization that will receive your information)
Person's Name or Organization:
Address:
Telephone #:
Person's Name or Organization:
Address:
Telephone #:
Description of the Information to be Released: (What type of information will be released)
Entire Health Record
Other, please describe
This authorization will expire (Check ONLY ONE Box):
When I revoke this authorization.
Upon the following date, event, or condition:
If I fail to specify an expiration date, this authorization will expire in twelve (12) months from the date of this signing.
I understand that this authorization to release information is voluntary and is not a condition of enrollment in ARBenefits Health
Plan, eligibility for benefits, or payment of claims. I also understand that once the information is disclosed pursuant to this
authorization, it may be disclosed by the recipient and the information may not be protected by federal privacy regulations. I
understand that the information in my health record may include information relating to sexually transmitted diseases, behavioral or
mental health services, and treatment for alcohol and drug abuse.
By signing below, I authorize the release of my protected health information as described above.
For EBD Use Only
Signature of Member or Legal Representative
Member ID#:
_
Printed Name of Member or Legal Representative
Completed By
Date
Employee Benefits Division - ARBenefits
PO Box 15610
Little Rock, AR 72231
877.815.1017
*
*
*
Rev. 10/14/19
2000-f-10
Department of Transformation and Shared Services
Governor Asa Hutchinson
Secretary Amy Fecher
Director Chris Howlett
Phone: (501) 682-9656
Toll Free: (877) 815-1017
Fax: (501) 682-1168
http://www.ARBenefits.org
Authorization to Release Information
This form is used to release your protected health information as required by federal and state privacy laws. Your authorization allows
EBD (ARBenefits) to release your protected health information to a person or organization that you choose. You can revoke this
authorization at any time by submitting a request in writing to EBD. Revoking this authorization will not affect any action taken prior to
receipt of your written request.
Member Information: (individual whose information will be released)
Name:
Member ID #:
Date of Birth:
Address:
Telephone #:
I authorize EBD (ARBenefits) to release my protected health information as described below
Recipient: (Person or organization that will receive your information)
Person's Name or Organization:
Address:
Telephone #:
Person's Name or Organization:
Address:
Telephone #:
Description of the Information to be Released: (What type of information will be released)
Entire Health Record
Other, please describe
This authorization will expire (Check ONLY ONE Box):
When I revoke this authorization.
Upon the following date, event, or condition:
If I fail to specify an expiration date, this authorization will expire in twelve (12) months from the date of this signing.
I understand that this authorization to release information is voluntary and is not a condition of enrollment in ARBenefits Health
Plan, eligibility for benefits, or payment of claims. I also understand that once the information is disclosed pursuant to this
authorization, it may be disclosed by the recipient and the information may not be protected by federal privacy regulations. I
understand that the information in my health record may include information relating to sexually transmitted diseases, behavioral or
mental health services, and treatment for alcohol and drug abuse.
By signing below, I authorize the release of my protected health information as described above.
For EBD Use Only
Signature of Member or Legal Representative
Member ID#:
_
Printed Name of Member or Legal Representative
Completed By
Date
Employee Benefits Division - ARBenefits
PO Box 15610
Little Rock, AR 72231
877.815.1017
*
*
*
Rev. 10/14/19
2000-f-10