Arkansas Authorization to Release or Obtain Medical Information Form
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3215 N. North Hills Blvd.
Fayetteville, Arkansas 72703
AUTHORIZATION TO RELEASE OR OBTAIN MEDICAL INFORMATION
Patient Name_____________________________________________________________________________
Birthdate:_________ Social Sec. No:_________________ Home Phone:____________ Work Phone:_________________
Address:____________________________________ City:______________ State:________ Zip:_____________
I hereby authorize WRMC to release information to:

I hereby authorize WRMC to release information from:

Name of Facility or Person

Name of Facility or Person

Address

Address

City, State, Zip Code

City, State, Zip Code

Telephone Number (include area code)

Telephone Number (include area code)

Purpose of the Requested Use or Disclosure(indicate specific reasons):_____________________________________________
Please Check the Types of Records to Be Released: (Date of Service)___________________________________________
__Complete Medical Record
__Discharge Summary
__Operative report
__