HIPAA Privacy Office - Forms

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HIPAA Privacy Office - Forms




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The following forms apply to the UT Southwestern Ambulatory Services (Clinics).

HIPAA Forms

Alternate Communications Request Form

Authorization for Audio Recordings and Photography

HIPAA Authorization for Research Purposes

HIPAA Authorization for Research Purposes (Spanish)

HIPAA Authorization for Verbal Release of PHI

HIPAA Authorization to Disclose PHI

HIPAA Confidentiality Agreement

HIPAA Data Extraction Report Request Form

Medical Record Amendment Request Form

Notice of Privacy Acknowledgment of Receipt

Notice of Privacy Practices Acknowledgment of Receipt (Spanish)

HIPAA Privacy Complaint Form

HIPAA Privacy Complaint and Resolution Form

Request for Accounting of Disclosures

Restriction Request Form for Use and Disclosure of Protected Health Information

Termination of Request for Restriction

Waiver of Authorization for Research Purposes