HIPAA Authorization Form-North Little Rock Location
* required field

HIPAA Authorization Form




I authorize Arkansas Dermatology to disclose my PHI (Protected Health Information) to the following providers and (or) facilities in regards to my treatment.





I authorize Arkansas Dermatology to disclose my PHI (Protected Health Information) to any person(s) indicated other than providers. This would include family, friends, guardian, POA...



If you do not authorize the release of your information leave the above blank and sign below.



Security Measure