Information may be released in writing, verbally, or by video, fax, photocopy, or microfilm. Reasonable copying costs may be assessed.
NOTICE TO PATIENT/PATIENT REPRESENTATIVE: Certain information disclosed pursuant to this Authorization may be subject to redisclosure by the recipient and may no longer be protected by federal privacy laws and regulations.
This Authorization may be revoked by notifying Youth Home, Inc. in writing addressed to:
Attention: Medical Records
Youth Home, Inc.
20400 Colonel Glenn Road
Little Rock, Arkansas 72210
Protected health information may already have been disclosed before the revocation is received. If so, the revocation will be effective only as of the date it is received by Youth Home, Inc.
This Authorization is voluntary. A refusal to sign will not affect the patient’s ability to obtain treatment, payment, or, if applicable, enrollment in a health plan or eligibility for benefits. A photocopy or fax of this Authorization shall be as valid as the original.