Dhs 4000-2025

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The document is an authorization form from the Arkansas Department of Human Services that allows a client or their personal representative to disclose specific health information to a designated recipient. It outlines the types of medical records that can be shared, the conditions under which the authorization is valid, and the client's rights regarding revocation and confidentiality of sensitive information. The form also includes a revocation section for clients wishing to rescind their authorization.

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Click ‘Get Form’ to open the dhs 4000 in the editor.
Begin by entering the Client Name and Mailing Address in the designated fields. Ensure accuracy as this information is crucial for identification.
Fill in the Client ID # and Date of Birth. This helps in verifying the client's identity and linking to their health records.
In the authorization section, specify who you are authorizing to disclose health information by entering their name and details.
Clearly state the purpose of disclosure in the provided field. This could be for treatment, payment, or other specified reasons.
Indicate what specific information is to be disclosed. You can select 'All Medical Records' or specify particular documents if needed.
Set an expiration date for this authorization. If left blank, it will remain valid for up to one year unless revoked earlier.
Sign and date the form at the bottom. If applicable, have a witness sign as well.

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What does DHS mean in medical terms?

Demographic and Health Surveys (DHS) are nationally-representative household surveys that provide data for a wide range of monitoring and impact evaluation indicators in the areas of population, health, and nutrition.

What does DHS stand for in healthcare?

How do I report? To report child abuse or neglect in Arkansas, you can call the Child Abuse Hotline at 1-800-482-5964 (TDD: 1-800-843-6349), or if you are a mandated reporter you can submit a report through a secure online portal at mandatedreporter.arkansas.gov.

How do I report someone to DHS in Arkansas?

Use Form 590, Withholding Exemption Certificate, to docHub an exemption from nonresident withholding. Form 590 does not apply to payments of backup withholding. For more information, go to ftb.ca.gov and search for backup withholding. Form 590 does not apply to payments for wages to employees.