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Washington University in St. Louis

HIPAA Privacy Office

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Forms

Patient Rights ​

Accounting of Disclosures Request ​

Accounting of Disclosures Request-WUPI

Alternative Methods of Communication​ Request

Amendment of Protected Health Information​ Request

Amendment of Protected Health Information Request-WUPI 

Medical Records Request

Medical Records Request-WUPI

Patient Communication Request

Restriction on Use or Disclosure of Protected Health Information Request

Restriction to Health Plan Request (Self-Pay)

Authorizations​

Authorization to Use Unsecured Email/Text for Clinical Services

Joint Authorization for Media Release

Authorization to Use Unsecured Email/Text Messaging for Research Studies

Confidentiality Agreements​

Confidentiality Agreement-Adult

Confidentiality Agreement-Minor

WU Business Associate Agreement (BAA)

Business Associate Agreement

HIPAA Privacy Office

660 S. Euclid Avenue | Campus Box 8098

Saint Louis, MO 63110

Phone: 314-747-4975

Toll-free: 866-747-4975

Fax: 314-273-1178

hipaa@wustl.edu

Information Security

If you have a question or concern related to data encryption, ePHI storage, or stolen devices, please contact the Information Security Office.

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