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Privacy Forms For Use By Clinics

  1. Patient Rights – HIPAA Privacy
  2. Clinic Operations HIPAA Forms
  3. Business Associate Forms


 A. Patients Rights - HIPAA Privacy Forms
 B. Clinic Operations -HIPAA Forms
Accounting of Disclosures — Log (Rev 6/2011)
Accounting of Disclosures — Request (Rev 6/2011)
Acknowledgment of Receipt of Notice of Privacy Practices (NPP) (Rev 6/2010)

Alternative Means of Communication — Request (Rev 6/2010)
Amendment of Protected Health Information (Rev 6/2010)
Athletics Department
Authorization to Release/Request for an Individual's Health Information/Treatment and Education Records (Rev 4/2012)
Authorization to Release/Request an Individual's Health Information/Treatment and Education Records (Goddard) (Rev 1/2012)
Authorization for Release of Protected Health Information, Including Image and Voice, to the Public Publicity/ Marketing (Rev 2/2013)
Authorization for Verbal Release of Protected Health Information (Rev 6/2011)
Authorization for Release/Use of Protected Health Information Videotape/Electronic Images (Rev 1/2013)
Authorization for Release/Use of Protected Health Information Videotape/Electronic Images - Minors (Rev 1/2013)
Authorization to Use or Disclose Protected Health Information to Communicate About Certain Products, Services, Treatments, or Operations (Rev 5/2013)
Consent for Electronic Communication (Rev 6/2011)
Consent for Use of Protected Health Information — In-Office Treatment, Payment, and Operations (Rev 11/2011)
Directory Opt-Out Form — George Nigh Rehabilitation Institute (only) (6/2010)

Individual's Health Information/Authorization to Release
(see above — Authorization to Release/Individual's Health Information)
 
Privacy Complaint Form (Rev 6/2010)
Restrictions on Use and Disclosures of Protected Health Information, Request (Rev 6/2011)
Revocation of Request for Restrictions on Use and Disclosure of Protected Health Information (Rev 7/2011)
Department of Human Services - Release of Information Regarding - Minor (Rev 6/2012)
Department of Human Services - Release of Information Regarding - Adult (Rev 3/2013)

 

Electronic Medical Record Access Agreement for External Users (Rev 5/2013)
Electronic Notice of Privacy Practices - Request and Revocation (Rev 8/2012)
Fax Cover Sheet for Protected Health Information (8/2011)
Law Enforcement Release (Rev 1/2013)
Notice of Disclosure of Personally Identifiable Student Information (Rev 6/2010) (This Notice is to be used as a cover sheet any time student education/treatment records are released.)
Role-Based Access Worksheet (10/2012) (This form is to be completed by the manager for all workforce members.)
Training and Education Request Form (Rev 6/2010)
University of Oklahoma Confidentiality Agreement (Volunteers/Visitors) (Rev 8/2011) (This Agreement is to be used for all volunteers at HSC and in Norman Campus HCCs, as well as for visitors or observers who, as part of an educational program or experience, may have access to patients or Protected Health Information.)
 
 
 
 C. Business Associate Forms

Business Associate (BA) Decision Chart (Rev 6/2010)

Mutual Business Associate Agreement (Rev 3/2013)

Business Associate Agreement Stand Alone (Rev 3/2013)

Business Associate Agreement for Health Care Components (HCCs) (Rev 3/2013)
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Phone: (405) 271-2511, (866) 836-3150
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