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. Initials document the Patient’s request but do not replace a standalone authorization or consent when governing law requires one. In particular, psychotherapy notes and Part 2 records must not be released solely on these initials; attach a compliant standalone document.

Part 2 warning: Initialing this general authorization does not itself create a consent that satisfies 42 C.F.R. § 2.31. Use a standalone consent containing every applicable current § 2.31 element. If the records will be used or disclosed in a civil, criminal, administrative, or legislative investigation or proceeding, § 2.31(d) prohibits combining that consent with a consent for any other purpose. Each disclosure made under a valid consent must also carry one of the notices permitted by § 2.32(a) and a copy of the consent or a clear explanation of its scope under § 2.32(b).

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