Medical Records & Forms

Records & Forms
 
 

 

Personal medical information and records are confidential, so a signed authorization form is required to receive a copy of your medical records. 

 

To get a copy of your medical records:

  1. Complete the Release of Medical Records Form (form can also be picked up at the health center). Note: All fields need must be filled in. Be sure to sign and date the bottom of the form.

  1. Email a completed authorization form and a copy of photo ID to: Buena Burks, Health Information Management Specialist.

Please allow up to 7-10 business days for processing.

 

Medical Records Charges: $10.00 (processing fee) plus $0.50 per page for first 25 pages ($0.25/page after). No charge for physicians/medical institutions.

Other Charges:

  • Verification of psychiatric disability: $50.00

  • Radiology images: $5.00

  • Additional microfilm retrieval fee of $10.00 (for any protected health information). 

Cash, Check, VISA, MasterCard, Discover and RazorBuck$ accepted. Checks payable to University of Arkansas.

 

Questions? Contact the Health Information Management Department or call 479-575-4451 (option 1). 

Forms

Absence Explanation

Authorization for Treatment of Minor

Immunization Compliance

Physician Request for Lab Orders

Release of Medical Records

Medical Services Charges Policy

CAPS Release of Confidential Information Authorization

Patient Rights & Responsibilities

 

Class Excuse Policy

The Pat Walker Health Center does not provide class excuses.

Because of federal health care privacy regulations, we cannot release protected health information (including dates and times services performed). 

If an illness prevents a student from attending classes for an extended period of time, the Dean of Students will be notified with the student’s permission.

Students and faculty may find it useful to use the Absence from Class Form as a means to have appropriate communication about class absences.