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ARKANSAS DEPARTMENT OF HUMAN SERVICESAUTHORIZATION TO DISCLOSE HEALTH INFORMATIONREVOCATION SECTIONI do hereby request that this authorization to disclose health information of(Name ofClient)signed by-(Enter- -Name- -ofPerson- - - Who- -Signed- -Authorization)---------be rescinded effective- - - -(Date)-----on(Enter Date ofSignature)I understand that any action taken on this authorization prior to therescinded date is legal and binding.(Signature ofClient)(Date)(Signature ofPersonal Representative)(Date)(Signature of Witness)(Date)(Personal Representative Relationship/Authority)The Department of Human Services is in compliance with Titles VI and VII of the Civil Rights Act. This letter isavailable in other languages and alternate formats.DHS-4000 (R. 11/05)Page2 of2

ARKANSAS DEPARTMENT OF HUMAN SERVICESDivision of County OperationsDECLARATION OF U.S. CITIZENSHIP OR SATISFACTORY IMMIGRATION STATUSIf you need this material in a different format such as large print, contact your DHS county office.Case No.CaseheadCountyFederal law requires that a written declaration of U.S. citizenship or lawful alien status be made for each individualapplying for or receiving Transitional Employment Assistance (TEA), Medicaid, or Food Stamps.Please check the appropriate box and list names as requested.DI declare that the persons listed on page 1 of my application form are U.S. Citizens or Nationals.DI declare that I am a U.S. Citizen or National.DI declare that the following persons are aliens who are:1) lawfully admitted for permanent residence; or 2) refugees; or (3) asylees; or 4) parolees with statusgranted for at least one year; or 5) individuals whose deportation is withheld; or 6) conditional entrantsINS#INS#INS#DI declare that the following persons are lawfully admitted aliens who are 1) U.S. military veterans with anhonorable discharge; or 2) active duty servicepersons; or 3) spouses or children of #1 or #2.Form#Form#0Other Specify INS StatusINS#INS#I declare under penalty of perjury that the foregoing is true and correct. (28 USC 1746)SignatureDateIf you have any questions regarding this form, please contact:County Office RepresentativeDC0-9 (R. 7/97)Phone Number

A R K A N I A IDIPARTMINT OPt.1: IMPORTANT NOTICEPLEASE READ BEFORE COMPLETING APPLICATION FOR BENEFITSThe PRIVACY ACT of 1974 requires the Department of Human Services (OHS) to tell you three (3) things about yourSocial Security Number (SSN). OHS must tell you: (1) whether disclosure is voluntary or mandatory; (2) how OHS willuse your SSN; and, (3) the law or regulation that allows OHS to ask you for the SSN. If a household member does nothave a Social Security Number, OHS will help the person apply for a number. A parent may refuse to disclose his or herSSN without affecting the benefits of an eligible child.Please sign and date this notice at the bottom. Also, please initial in the space provided before each type of benefit forwhich you are applying.Supplemental Nutrition Assistance Program (SNAP): As a condition of eligibility for benefits, eachhousehold member must furnish his or her Social Security Number to OHS. Federal laws 7 U.S.C. § 2025(e) and 42 U.S.C. § 1320b-7(b) (4) and OHS Food Stamp Certification Manual§ 2100 make OHS collectyour number before approving your SNAP application.* Disclosure of your Social Security Number isvoluntary. However, a person who does not provide the number, or apply for one, will not be eligible toreceive benefits.Medicaid: As a condition of eligibility, each applicant for or recipient of Medicaid must furnish his or herSocial Security Number to OHS. Federal laws 42 U.S.C. §§ 1320b-7(a) (1) and 1320b-7(b) (2) and OHSMedical Services Policy Manual § 1390 make OHS collect your number before approving your Medicaidapplication.*. Disclosure of your Social Security Number is voluntary. However, a person who does notprovide the number, or apply for one, will not be eligible to receive benefits.TEA (TANF): As a condition of eligibility, each applicant for or recipient of TEA (TANF), benefits mustfurnish OHS his or her Social Security Number. Federal laws 42 U.S.C. §§ 1320b-7(a) (1) and 1320b-7(b)(2) and DHS Transitional Employment Assistance Manual § 2110 make DHS collect your SSN beforeapproving your application.* Disclosure of your Social Security Number is voluntary. However, a personwho does not provide the number, or apply for one, will not be eligible to receive benefits.*If someone does not have an SSN, DHS will help the person apply for one. As long as an SSN application isfiled with the Social Security office, the DHS application may be approved.In all of the above programs, DHS uses Social Security Numbers for program applicants and participants: To access information To determine eligibility To verify wages, unearned income, and other information To prevent duplicate participation To facilitate mass changes in Federal benefits To determine the accuracy and reliability of informationIn addition, SSN's are used for matters related to collection of child support for TEA program participants.Printed NameSignature Date.AddressCity State ZipDCO-0092 (R. 03/09)

ARKANSAS DEPARTMENTOF HUMAN SERVICESNOTICE OF PRIVACYPRACTICESFor Health Care Operations: OHS may use or disclose your PHI for the purposeof our business operations. These uses and disclosures are necessary to insure ourpatients receive quality care. For example, we may use PHI to review the quality ofour treatment and services, and to evaluate the performance of staff, contractedemployees and students in caring for you.Updated: December 08, 2016Business Associates: We may use or disclose your PHI to an outside company thatassists us in operating our health system and performs various services for us. Thisincludes, but is not limited to, auditing, accreditation, legal services, dataprocessing, and consulting services. These outside companies are called "businessassociates" and contract with us to keep PHI received confidential in the same waywe do. These companies may create or receive PHI for us.THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUTYOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GETACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.The Department of Homan Services (DHS) provides many types of services,such as health and social services. OHS staff must collect information aboutyou to provide these services. OHS knows that information collected about youand your health is private. DHS and all associates at all locations are requiredby law to maintain the privacy of patients' Protected Health Information(PHI) and to provide individuals with the Notice of the legal duties andprivacy practices with respect to PHI.DHS is required to give you a notice of our privacy practices for theinformation we collect and keep about you. We are required to abide by theterms of this Notice. We reserve the right to change the terms of this Noticeand these new term will affect all PHI that we maintain at that time.Revised notices may be picked up at any office or online cs/PUB-407.pdfIn certain circumstances, DHS may ose and disclose PHI withoutwritten consent.For Treatment: We will use your health information to provide you with medicaltreatment or services. We will disclose PHI to doctors, nurses, technicians, studentsin health care training programs, or other personnel who are involved in takingcare of you. For example, a doctor treating you for a broken leg may need toknow if you have diabetes because that might slow the beating process. Inaddition, he/sbe may need to tell the dietitian to arrange for appropriate meals.Different departments of OHS may share health information about you in orderto coordinate the services you need, such as prescriptions, lab work and x rays. We may disclose health information to people outside OHS "110 provideyour medical care like nursing homes or other doctors. We may tell yourhealth insurer about treatment your doctor has recommended to obtain priorapproval to determine "1lether your plan will cover the cost of the treatment.We may contact you to provide reminders of appointments.For Payment: OHS will use and disclose PHI to other health care providersto assist in payment of your bills. For example, we will use it to send bills andcollect payment from you, your insurance company, or other payers, such asMedicare, for the care, treatment, and other related services you receive.OHS PUB-408, Effective Date: January 01, 2017For Public Health Activities: OHS may use or disclose your PHI for public healthactivities that are permitted or required by law. For example, we may disclosePHI in certain circumstances to control or prevent a communicable disease;injury; disability; to report births and deaths; and for public health oversightactivities or interventions. We may disclose PHI to the Food and DrugAdministration (FDA) to report adverse events or product defects, to trackproducts, to enable product recalls, or to conduct post-market surveillance asrequired by law or to state or federal government agencies. We may disclosePHI, if directed by a public health authority, to a foreign government agencythat is collaborating with the public health authority.For Health Oversight Activities:OHS may disclose PHI to a healthoversight agency for activities authorized by law. For example, these oversightactivities may include audits; investigations; inspections; licensure ordisciplinary actions; or civil, administrative, or criminal proceedings oractions. Agencies seeking this information include government agencies thatoversee the health care system, benefit programs, other regulato,y programs,and government agencies that ensure compliance with civil rights laws.As Required by Law and For Law Enforcement: OHS will use and disclose PHIwhen required or permitted by federal, state, and local laws, or by court order.Under certain conditions, we may disclose PHI to law enforcement officials for lawenforcement purposes. For example, these may include ( 1) responding to a courtorder or similar process; (2) as necessary to locate or identify a suspect, fugitive,material witness, or missing person; (3) reporting suspicious wounds, burnsor other physical iajuries; or (4) as relating to the victim of a crime.Lawsuits and Other Legal Proceedings: OHS may disclose PHI in the course ofany judicial or administrative proceeding or in response to an order of a court oradministrative tribunal (to the extent such disclosure is expressly authorized.) Ifcertain conditions are met, we may disclose your PHI in response to a subpoena, adiscove,y request, or other lawful process.Abuse or Neglect: We may disclose your PHI to a government authority that isauthorized by law to receive reports of abuse, neglect, or domestic violence.Additionally, as required by law, if we believe you have been a victim ofabuse, neglect, or domestic violence, we may disclose your PHI toa governmental entity authorized to receive it.For Government Programs: OHS may use and disclose PHI for public benefitsunder other government programs. For example, OHS may disclose PHI forthe determination of Supplemental Security Income (SSI) benefits.To Avoid Harm: OHS may disclose PHI to law enforcement in order to avoida serious threat to the health and safety of a person or the public.For Research: OHS may use and share your health information for certainkinds of research. For example, a research project may involve comparing thehealth and recove,y of patients "110 received one medication to those whoreceived another for the same condition. All research projects, however, aresubject to a special approval process. In some instances, the law allows us todo some research using your PHI without your approval.Family Memhen and Friends: If you agree, do not object, or we reasonably inferthat there is no objection, OHS may disclose PHI to a family member, relative,or other person(s) whom you have identified to be involved in your health care orthe payment of your health care. If you are not present, or are incapacitated, or itis an emergency or disaster relief situation, we will use our professionaljudgment to determine "1lether disclosing limited PHI is in your best interest. Wemay disclose PHI to a family member, relative, or other person(s) who wasinvolved in the health care or the payment for health care of a deceasedindividual if not inconsistent with prior expressed preferences of theindividuals known to OHS. You also have the right to request a restriction onour disclosure of your PHI to someone who is involved in your care.Coronen, Medical Examinen, and Funeral Directon: OHS may releaseyour PHI to a coroner or medical examiner. For example, this may be necessaryto identify a deceased person or to determine cause of death. We may alsorelease your PHI to a funeral director, as necessa,y, to car,y out his/her duties.Organ Donations: We will disclose PHI to organizations that obtain, bank,or transplant organs or tissues.National Security and Protection of the President: OHS may release yourPHI to an authorized federal official or other authorized persons forpurposes of national security, for providing protection to the President, or toconduct special investigations, as authorized by law.Correctional Institution: If you are an inmate of a correctional institutionor under the custody of a law enforcement officer, OHS may release yourPHI to them. The PHI released must be necessary for the institution to provideyou with health care, protect your or other's health and safety, or for the safetyand security of the correctional institution.Military: If you are a veteran or a current member of the armed forces, OHS

may release your PHI as required byadministration authorities.military command or veteranWorkers' Compensation: OHS will disclose your health information thatis reasonably related to a worker's compensation illness or injury followingwritten request by your employer, worker's compensation insurer, or theirrepresentative.Employer Sponsored Health and Wellness Services: We maintain PHI aboutemployer sponsored health and wellness services we provide our patients,including services provided at their employment site. We will use the PHIto provide you medical treatment or services and will disclose the informationabout you to others who provide you medical care.Shared Medical Record/Health Information Exchanges: We maintainPHI about our patients in shared electronic medical records that allow theOHS associates to share PHI. We may also participate in various electronichealth information exchanges that facilitate access to PHI by other health careproviders who provide you care. For example, if you are admitted on anemergency basis to another hospital that participates in the health informationexchange, the exchange will allow us to make your PHI available electronically tothose who need it to treat you.Sponsor of the Plan: OHS may disclose PHI to the sponsor of a group healthplan or a health insurance issuer.Other Uses and Disclosures of PHIOther uses and disclosures of your PHI that are not described above will be madeonly with your written authoriz.ation. If you provide OHS with an authorization,you may revoke it in writing, and this revocation will be effective for future usesand disclosures of PHI. The revocation will not be effective for information thatwe have used or disclosed in reliance on the authorization.For example, most uses and disclosures of psychotherapy notes, uses anddisclosures of PHI for marketing purposes, and disclosures that constitute the saleof PHI require your written authorization.Your PHI Privacy RightsRight to Revoke Permission: If you are asked to sign an authorization to use ordisclose PHI, you can cancel that authorization at any time. You must make therequest in writing. This will not affect PHI that has already been shared.Right to Request Restrictions: You have the right to request certain restrictionsof our use or disclosure of your PHI. We are not required to agree to your requestin most cases. But if OHS agrees to the restriction, we will comply with yourrequest unless the information is needed to provide you emergency treatment.OHS will agree to restrict disclosure of PHI about an individual to a health plan ifthe purpose of the disclosure is to carry out payment or health care operations andthe PHI pertains solely to a service for which the individual, or a person other thanthe health plan, has paid OHS for in full. For example, if a patient pays for aservice completely out of pocket and asks OHS not to tell his/her insurancecompany about it, we will abide by this request. A request for restriction should bemade in writing. To request a restriction you must contact the OHS PrivacyOfficer. We reserve the right to terminate any previously agreed-to restrictions(other than a restriction we are required to agree to by law). We will inform you ofthe termination of the agreed-to restriction and such termination will only beeffective with respect to PHI created after we inform you of the termination.Right to Request Confidential Commnnications: You may request in writingthat we communicate with you in an alternative manner or at an alternativelocation. For example, you may ask that all communications be sent to your workaddress. Your request must specify the alternative means or location forcommunication with you. It also must state that the disclosure of all or part of thePHI in a manner inconsistent with your instructions would put you in danger. Wewill accommodate a request for confidential communications that is reasonable andthat states that the disclosure of all or part of your protected health informationcould endanger you.Right to Inspect and Copy: You have the right to inspect and receive a copy ofPHI about you that may be used to make decisions about your health. A request toinspect your records may be made to your nurse or doctor while you are aninpatient or to the OHS Privacy Officer while an outpatient. For copies of yourPHI, requests must go to the OHS Privacy Officer. For PHI in a designated recordset that is maintained in an electronic format, you can request an electronic copy ofsuch information. There may be a charge for these copies.Right to Amend: You may as

ARKANSAS DEPARTMENT OF HUMAN SERVICES TEFRA and AUTISM WAIVER Application for Assistance If you need this material in a different format, such as large print, please contact your local DHS county office. Si necesita este formulario en Espanol, flame al 1-800-482-8988 y pida la versi6n en Espal'lol. What type of services are you requesting?