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Notice of Privacy Practices/Notificacion De Practicas De Privacidad

Privacy Forms For Use By Patients

Formularios de Privacidad para su Utilización por los Pacientes

Clinics - Please use Privacy Forms-Clinics*

Clínica – Utilice los Formularios de Privacidad -Clínica*

HIPAA Privacy and Medical Record Forms

Formularios HIPAA de Privacidad e Historia Clínica

   
     
Accounting of Disclosures — Request (Rev 1/2016)    
   
Alternative Means of Communication — Request (Rev 1/2016)    
   
Amendment of Protected Health Information (Rev 1/2016)    
   
Request for Health Information/Treatment Records - Requesting Your Own Records (5/2016)    
  • Health Sciences Center
  • Español - Solicitud de Información de Salud/ Registros de Tratamiento Médic (Para Uso Cuando el Paciente Solicita Registros Propios/o de un Menor)
   
Authorization to Release Health Information/Treatment Records - Authorizing Release of Your Own Records to Others (Rev 5/2016)    
   

Authorization to Verbally Release Protected Health Information (Rev 5/2016)

   
   
Request and Consent for Electronic Communication (Rev 1/2016)    
  • Español - Consentimiento para comunicación electrónica – Correo electrónico seguro     

   
Consent for Use of Protected Health Information — In-Office Treatment, Payment, and Operations (Rev 1/2016)    
  • Español - Consentimiento De Utilizacion De La Informacion Medica Protegida Para Determinar El Tratamiento Medico, El Pago Del Tratamiento Y Para Realizar Las Demas Actividades Relacionadas Con El Cuidado Medico

   

Electronic Notice of Privacy Practices - Request and Revocation (Rev 1/2016)

   
  • Español -Notificacion De Practicas De Privacidad

   

Restrictions on Use and Disclosures of Protected Health Information, Request (Rev 1/2016)

   
   
Revocation of Request for Restrictions on Use and Disclosure of Protected Health Information - Health Sciences Center (1/2016)
  • Español - Revocación De La Solicitud De Restricciones Sobre Uso Y Divulgación De Información Protegida De Salud

 



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