Medical Records Authorization (HIPAA)

AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION (HIPAA) — ARKANSAS

This Authorization is executed in connection with a personal-injury matter so that the Patient and/or the Patient's attorney may obtain the Patient's medical records.

1. PATIENT IDENTIFICATION

2. PROVIDER(S) AUTHORIZED TO RELEASE RECORDS

I authorize the following medical provider(s), facility(ies), clinic(s), pharmacy(ies), laboratory(ies), insurer(s), or custodian(s) of records to release the Protected Health Information ("PHI") described below:

3. RECIPIENT(S) — PERSON(S) AUTHORIZED TO RECEIVE RECORDS

4. RECORDS AUTHORIZED FOR RELEASE

Date range of records: [__/__/____] to [__/__/____] (or ☐ all dates).

Check each category of records to be released:

• ☐ Complete medical chart / designated record set
• ☐ History and physical examination reports
• ☐ Office/progress/treatment notes
• ☐ Hospital and emergency department records
• ☐ Operative and surgical reports
• ☐ Physician orders
• ☐ Laboratory and pathology reports
• ☐ Radiology/imaging reports and films (X-ray, MRI, CT, ultrasound)
• ☐ Physical therapy / rehabilitation records
• ☐ Prescription and pharmacy/medication records
• ☐ Billing statements, itemized charges, and payment records
• ☐ Diagnostic test results
• ☐ Discharge summaries
• ☐ Narrative medical report / medical review (note: a reasonable fee may apply if specifically requested — Ark. Code § 16-46-106(d))
• ☐ Other (specify): [________________________________]

5. SPECIAL-CATEGORY RECORDS — SEPARATE SPECIFIC AUTHORIZATION REQUIRED

The following categories are protected by heightened confidentiality rules. They will NOT be released unless the Patient specifically initials the corresponding line below. My initials authorize release of that specific category to the Recipient(s) named in Section 3:

42 C.F.R. Part 2 notice (substance use disorder records): "42 CFR part 2 prohibits unauthorized use or disclosure of these records." Each disclosure made with the patient’s written consent must also be accompanied by a copy of the consent or a clear explanation of its scope. See 42 C.F.R. § 2.32.

6. PURPOSE OF DISCLOSURE

The purpose of this disclosure is:

• ☐ Legal representation / evaluation, prosecution, or settlement of the Patient's personal-injury claim (Ark. Code § 16-46-106 governs access in contemplation of or for use in a legal proceeding)
• ☐ At the request of the Patient
• ☐ Other (specify): [________________________________]

7. HIPAA REQUIRED STATEMENTS

7.1 Expiration. This Authorization expires on [__/__/____], or upon the following event: [________________________________]. If no date or event is specified, this Authorization expires upon final resolution of the Patient's personal-injury claim or three (3) years from the date of signature, whichever occurs first.

7.2 Right to Revoke. I understand that I may revoke this Authorization at any time by delivering written notice to the provider/custodian identified in Section 2. Revocation will not apply to information already released in reliance on this Authorization before the provider receives my written revocation. (45 C.F.R. § 164.508(c)(2)(i).)

7.3 No Conditioning of Treatment. I understand that the provider may not condition treatment, payment, enrollment, or eligibility for benefits on whether I sign this Authorization, except as permitted by 45 C.F.R. § 164.508(b)(4).

7.4 Redisclosure Notice. I understand that information disclosed under this Authorization may be redisclosed by the Recipient and may then no longer be protected by HIPAA. (Special-category records under Section 5 remain subject to the redisclosure prohibitions of 42 C.F.R. Part 2 and applicable Arkansas law.)

7.5 Right to a Copy. I understand that I am entitled to a copy of this signed Authorization.

7.6 Voluntary. I understand that signing this Authorization is voluntary.

8. ARKANSAS COPY-FEE AND RESPONSE-TIME NOTE

Under Ark. Code § 16-46-106, a patient (personally or through an authorized person, including an attorney) may obtain medical records by written request for use in a legal proceeding, insurance claim, or life-insurance underwriting. Statutory charges:

• Paper photocopies: no more than $0.50 per page for the first 25 pages and $0.25 per page for each additional page (excludes records in electronic format and X-ray copies).
• Labor charge: up to $25.00 per request (or, in the alternative, a reasonable retrieval fee for off-site stored paper records), plus actual postage.
• Certification/notarization: additional $2.00 if requested.
• Electronic records: must be furnished in electronic format and produced within 30 days of the request; the fee for producing electronic records is a flat $75.00 (plus actual postage), and that is the only fee allowed for electronic production.

Under the HIPAA right of access (45 C.F.R. § 164.524), a covered entity must generally act on a patient's own-record request within 30 days (with one 30-day extension on notice).

9. SIGNATURE

Personal Representative (if Patient is a minor, incapacitated, or deceased)

Notary (optional)

State of Arkansas, County of [________________________].

Subscribed and sworn to before me on [__/__/____] by [________________________________].

Sources and References

• HIPAA authorization core elements — 45 C.F.R. § 164.508: https://www.law.cornell.edu/cfr/text/45/164.508
• HIPAA right of access — 45 C.F.R. § 164.524: https://www.law.cornell.edu/cfr/text/45/164.524
• Substance use disorder records — 42 C.F.R. Part 2: https://www.ecfr.gov/current/title-42/chapter-I/subchapter-A/part-2
• Ark. Code § 16-46-106 (access to medical records; fees): https://law.justia.com/codes/arkansas/title-16/subtitle-4/chapter-46/subchapter-1/section-16-46-106/
• Act 765 of 2023 (amending § 16-46-106): https://www.arkleg.state.ar.us/Acts/FTPDocument?path=%2FACTS%2F2023R%2FPublic%2F&file=765.pdf&ddBienniumSession=2023%2F2023R