Authorization of Records from Highlands

Authorization for Release of Info from Highlands Oncology Group

  • I, hereby authorize Highlands Oncology to release to:

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  • Patient Information

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  • 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.
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  • Request to be accessed or released:

  • **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
  • 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.
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  • 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.