HIPAA Privacy Forms

The HIPAA Privacy Office (HPO) has developed forms to be used with our policies and procedures related to the HIPAA Regulation. These forms are to be used to support HIPAA Patient’s Rights and meet requirements outlined in the HIPAA Regulation.

PATIENT FORMS

Requests for Medical Records Access/Copies (Health Information Release Services)
HPF-001 Request for Accounting of Disclosure of Protected Health Information Form – WUSM
HPF-002 Request for Accounting of Disclosure of Protected Health Information Form – WUPI
HPF-003 Accounting of Disclosures of Protected Health Information Report Form
HPF-004 Request for Amendment of Protected Health Information Form – WUSM
HPF-005 Request for Amendment of Protected Health Information Form – WUPI
HPF-007 Patient Communication Form
HPF-009 Request for Restrictions on Uses or Disclosures of Protected Health Information Form
HPF-010 Request for Alternative Methods of Confidential Communications Form
HPF-011 Request for Restriction to Health Plan Self-Pay Form

AUTHORIZATION FORMS

WU/BJC – Joint Authorization for Media Release Form
HPF-012 Authorization to Use Unsecured Email and Text Messaging for Clinical Services Form
HPF-013 Authorization to Use Unsecured Email and Text Messaging for Research Studies Form

CONFIDENTIALITY AGREEMENTS

HPF-014 Confidentiality Agreement – Adult
HPF-015 Confidentiality Agreement – Minor

WU BUSINESS ASSOCIATE AGREEMENT

WU Business Associate Agreement