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ERAVE User Application Form - Arkansas Department of Health

ERAVE User Application Form - Arkansas Department of Health 2025

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The document is an application form for users seeking access to the Electronic Registration of Arkansas Vital Events (ERAVE) system, managed by the Arkansas Department of Health. It outlines the necessary applicant information, including personal details and professional roles related to vital records. The form emphasizes the legal responsibilities associated with using the system and requires a signed agreement to ensure compliance with state regulations regarding the filing of birth, death, and stillbirth certificates.

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Click ‘Get Form’ to open the ERAVE User Application Form in our editor.
Begin by filling out the Applicant’s Data section. Ensure you complete all required fields marked with an asterisk, including your First Name, Last Name, Business Address, City, State, Zip, Primary Phone, and Email Address.
In the ERAVE Roles section, list each group/location combination separately. Refer to the provided Permission Groups and select the appropriate roles that apply to you.
If applicable, enter your License Number and License Type in the designated fields. This is mandatory for certain professionals like Physicians and Funeral Directors.
Review the user agreement carefully. By signing below, you confirm your understanding of the system's purpose and agree to its terms.
Finally, save your completed form and choose to email it to ADHERAVE@arkansas.gov or fax it to 501-683-6646 as instructed.

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How to fill out an authorization for release of health information?

Begin by specifying your name, the entity authorized to disclose information, and the individuals or entities you authorize to receive it. Indicate the specific information and purpose for which it will be disclosed, add an expiration date or event, and sign and date the form to confirm your consent.

What is erave?

The ERAVE system provides authorized users a secure, online method for submitting and managing reports of vital events including deaths, infant hearing screenings, births, and fetal deaths.

What is an example of a HIPAA authorization?

I hereby authorize use or disclosure of protected health information about me as described below. 4. I understand that the information used or disclosed may be subject to re-disclosure by the person or class of persons or facility receiving it, and would then no longer be protected by federal privacy regulations.

How to fill out an authorization letter?

How do I write a simple letter of authorization? Start with your name and contact information at the top. Include the current date. Write the recipients name and contact information. Clearly state your name and that youre writing to grant authorization to another individual or organization.

How do you write an authorization letter for medical records release?

I, the undersigned, authorize the release of, or request access to the information specified below from the medical record(s) of the above name patient. I understand that my records are confidential and cannot be disclosed without my written authorization, except when otherwise permitted by law.

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