Authorization of Records from Highlands

Authorization for Release of Info from Highlands Oncology Group

I, hereby authorize Highlands Oncology to release to:
Name
Phone
Hidden
Email
Fax Number
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Patient Information
Patient Name*
First Middle Last
Patient Phone Number*
Patient Date of Birth*
MM slash DD slash YYYY
Patient Medical Record Number
Information is to be limited to the following dates (if applicable)
Only enter dates below if you’d like your information to be limited to a certain period of time.
Beginning Date
MM slash DD slash YYYY
Ending Date
MM slash DD slash YYYY
Request to be accessed or released:
Records from:
Records to:
**Records of other providers on file with H.O.G.,(if any) may not be the complete records of the other providers. If you want a complete copy of those records, you may want to contact them individually.**

I understand that if the records requested to be released include information relating to sexually transmitted diseases, AIDS or HIV, alcohol or drug abuse, or mental health information, a separate signed authorization will be required by the patient.

For clinical billing records, please contact the North Hills Billing Representative at (479) 587-1700 OR the Bentonville Billing Representative at (479) 936-9900
Purpose of release is, at the request of the:*
Expiration Date
This authorization will expire 90 days from the date on which it was signed unless I specify a different time period. I understand that I may revoke this authorization at any time by giving written notice to Highlands Oncology. A revocation of this signed authorization will not apply to records already released. A photocopy of this signed authorization shall constitute a valid authorization.
Expiration Date
MM slash DD slash YYYY
Highlands Oncology, its employees and physicians are released from legal responsibility or liability for the release of above information to the extent indicated and authorized herein.

I understand that once the above information is disclosed, it may be re-disclosed by the designated recipient and the information may no longer be protected by federal privacy laws.

Highlands Oncology will not condition treatment, payment, enrollment or eligibility for benefits upon signing this authorization.
Signature*
By checking this box you agree to the above statement.

Authorization of Records from Highlands

Authorization for Release of Info from Highlands Oncology Group

I, hereby authorize Highlands Oncology to release to:

Patient Information

Information is to be limited to the following dates (if applicable)

Request to be accessed or released:

Expiration Date