AUTHORIZATION FOR DISCLOSURE OF INFORMATION
We care about your privacy, and that is why only the people who have both the need and the legal right may see your protected health information may do so. We are required by law to maintain the privacy of your PHI and to notify you if a breach of your unsecured PHI occurs. Unless you give us permission or authorization in writing, we will only use or disclose the minimum necessary health information for purposes of treatment, payment, healthcare operations, when we are required by law to do so, or for other reasons listed in our HIPAA and Privacy Policies on the LRCMHC website.

To request and authorize Little Rock Community Mental Health Center, Inc. (LRCMHC) to release and obtain information, please complete this Authorization for Disclosure of Information form. Completion and electronic signature on this form constitutes a legal authorization to release or obtain your personal health information.

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