2000-F-10 Authorization To Release Health Information Form

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EBD
State of Arkansas
Department of Finance
Employee Benefits Division
Post Office Box 15610
and Administration
Little Rock, AR 72231-5610
Phone: (501) 682-9656
Toll Free: (877) 815-1017
Fax: (501) 682-1168
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 __________________________________________________________________________
Expiration: (When this authorization will end)
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
Rev. 11/15/11
2000-f-10

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