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Notice of Privacy Practices

Privacy Forms For Use By Patients*

*(Clinics - Please use Privacy Forms-Clinics)

HIPAA Privacy and Medical Record Forms

Accounting of Disclosures — Request (Rev 6/2011)
George Nigh Rehabilitation Institution Optimized for Microsoft Word 2003 Optimized for Microsoft Word 2007 Health Sciences Center Optimized for Microsoft Word 2003 Optimized for Microsoft Word 2007 Norman Campus Optimized for Microsoft Word 2003 Optimized for Microsoft Word 2007
Alternative Means of Communication — Request (Rev 6/2010)
George Nigh Rehabilitation Institution Optimized for Microsoft Word 2003 Optimized for Microsoft Word 2007 Health Sciences Center Optimized for Microsoft Word 2003 Optimized for Microsoft Word 2007 Norman Campus Optimized for Microsoft Word 2003 Optimized for Microsoft Word 2007
Amendment of Protected Health Information (Rev 6/2010)
George Nigh Rehabilitation Institution — Request to Amend Optimized for Microsoft Word 2003 Optimized for Microsoft Word 2007 Health Sciences Center — Request to Amend Optimized for Microsoft Word 2003 Optimized for Microsoft Word 2007 Norman Campus — Request to Amend Optimized for Microsoft Word 2003 Optimized for Microsoft Word 2007
Authorization to Release/Request for an Individual's Health Information/Treatment and Education Records (Rev 4/2012)
Optimized for Microsoft Word 2003 Optimized for Microsoft Word 2007 Spanish Version Optimized for Microsoft Word 2003 Optimized for Microsoft Word 2007
Authorization to Release/Request an Individual's Health Information/Treatment and Education Records (Goddard) (Rev 1/2012)
Optimized for Microsoft Word 2003 Optimized for Microsoft Word 2007
Authorization for Verbal Release of Protected Health Information (Rev 6/2011)
Optimized for Microsoft Word 2003 Optimized for Microsoft Word 2007 Spanish Version Optimized for Microsoft Word 2003 Optimized for Microsoft Word 2007
Consent for Electronic Communication (Rev 6/2011)
Optimized for Microsoft Word 2003 Optimized for Microsoft Word 2007
Consent for Use of Protected Health Information — In-Office Treatment, Payment, and Operations (Rev 11/2011)
Optimized for Microsoft Word 2003 Optimized for Microsoft Word 2007 Spanish Version Optimized for Microsoft Word 2003 Optimized for Microsoft Word 2007
Directory Opt-Out Form — George Nigh Rehabilitation Institute (only) (Rev 6/2010)
Optimized for Microsoft Word 2003 Optimized for Microsoft Word 2007
Electronic Notice of Privacy Practices - Request and Revocation (Rev 8/2012)
Optimized for Microsoft Word 2003 Optimized for Microsoft Word 2007
Restrictions on Use and Disclosures of Protected Health Information, Request (Rev 6/2011)
George Nigh Rehabilitation Institution Optimized for Microsoft Word 2003 Optimized for Microsoft Word 2007 Health Sciences Center Optimized for Microsoft Word 2003 Optimized for Microsoft Word 2007 Norman Campus Optimized for Microsoft Word 2003 Optimized for Microsoft Word 2007
Revocation of Request for Restrictions on Use and Disclosure of Protected Health Information - Health Sciences Center (Rev 7/2011)
Optimized for Microsoft Word 2003 Optimized for Microsoft Word 2007

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Office of Compliance
940 Stanton L. Young Blvd., Room 127
Oklahoma City, Oklahoma 73104
Phone: (405) 271-2511, (866) 836-3150
Fax: (405) 271-1768