Patient Authorization for Exchange of Vaccination Information Between Access Medical Clinic and the University of Arkansas Athletics Department

I hereby authorize Access Medical Clinic to disclose my COVID vaccination information to the University of Arkansas Athletics Department. I have received my COVID vaccination, and I authorize the University of Arkansas Athletics Department to contact me regarding tickets to a U of A football game.

This authorization covers only disclosure of my COVID vaccination information and my contact information listed below and no other Protected Health Information about me.

This authorization will expire at the time Access Medical Clinic provides my vaccination information and contact information to the University of Arkansas.

I am consenting to this authorization voluntarily in order to be eligible for an incentive for receiving my COVID vaccination.

This ticket incentive from Access Medical Clinic is subject to availability and limited to one (1) per patient receiving a vaccination at an Access Medical Clinic location.