HIPAA Authorization
By signing below, you give permission and authorize UAMS to release to the UAMS
Office of Communications and Marketing information about your treatment and medical conditions,
your child’s treatment and medical conditions, the photos you uploaded, why you chose UAMS
and why you had a great experience at UAMS. This information will be used on UAMS
websites and social media for marketing purposes.
I understand that I may revoke this authorization at any time by giving written notice to UAMS
by mail at 4301 West Markham, Slot 890, Little Rock, Arkansas, 72205 or by email at marketing@uams.edu.
A revocation of this authorization will not apply to records already released in reliance upon the authorization.
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 and regulations.
UAMS will not condition treatment, payment, enrollment, or eligibility for benefits on your signing of this authorization.
I understand this authorization will expire when UAMS no longer needs my health information
or my child's health information to use on UAMS websites and social media for marketing purposes.
By signing below, I am signing as the patient and the Legal Representative of my child having authority to sign as the parent.
