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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 9/2013)    
   
Alternative Means of Communication — Request (Rev 9/2013)    

 

   
Amendment of Protected Health Information (Rev 9/2013)    
   
Authorization to Release/Request for an Individual's Health Information/Treatment and Education Records (Rev 10/2013)    
   

Authorization to Release/Request an Individual's Health Information/Treatment and Education Records (Goddard) (Rev 10/2013)

   
   

Authorization for Verbal Release of Protected Health Information (Rev 6/2011)

   
   
Consent for Electronic Communication Secure Email (Rev 9/2013)    
   
Consent for Use of Protected Health Information — In-Office Treatment, Payment, and Operations (Rev 11/2011)    
   

Electronic Notice of Privacy Practices - Request and Revocation (Rev 8/2012)

   
   
Restrictions on Use and Disclosures of Protected Health Information, Request (Rev 9/2013)    
   
Revocation of Request for Restrictions on Use and Disclosure of Protected Health Information - Health Sciences Center (7/2011)
 



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