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Form # SY2/NPPARF-002 / 11.03 (Rev. 10.01.14) White – Health Information Management Department Yellow – Patient (Reviewed 09/13) Page 1 of 1 NOTIFICACIÓN DE PRACTICAS DE PRIVACIDAD RECONOCIMIENTO DE RECIBO DEL AVISO Su firma abajo indica que le han ofrecido una copia del aviso medico de UT …

Form # FMA/RADI-001 / 03.03 (Rev. 08/15) (Reviewed 09/13) Page 1 of 1 You have the right to request that UT Southwestern Medical Center provide an accounting of certain disclosures of your protected health information. An accounting of disclosures may include disclosures up to 6 years prior t…

Nombre del paciente: _________________________________ Dirección: __________________________________________ __________________________________________________ Ciudad Estado Código postal N.º de expediente médico: Fecha de nacimiento: Sexo: Autorización …

Strategic Planning and Implementation Nov. 24, 2009 To the UT Southwestern Community: I am writing to thank all who participated in our Strategic Planning Initiative through the summer and to let the entire UT Southwestern community know about some initial important decisions that have be…

White – Health Information Management Department Yellow – Patient Page 1 of 2 Form # 7680-001 / 01.05 (Rev. 06/13/18) Authorization to Disclose Protected Health Information Instructions: Complete all applicable sections to have information disclosed from UT Southwestern Medical Center to ano…

Form # OCA/PCF-001 / 07.12 (Reviewed 09/13) Page 1 of 1 PRIVACY COMPLAINT FORM For Patient Use Only For Internal Use Only Tracking Number If you have questions about completing this form, please call 214-648-6080 and leave a message. Date Your First Name Your Last Name Home Phone ( …

Form # NPPARF-001 / 03.05 (Rev. 12.11) White – Health Information Management Department Yellow – Patient Reviewed 09/13 Page 1 of 1 Notice of Privacy Practices Acknowledgement of Receipt Form Your signature below indicates that you have been offered a copy of UT Southwestern Medical Center…

Form # FMA/MRARF-001 / 03.03 (Rev. 03.16) Reviewed 09/13 Page 1 of 2 Medical Record Amendment Request Form Pt. Name:______________________________________________ Address:_______________________________________________ ______________________________________________________ City …

Financial Update from President Daniel K. Podolsky, MD February 23, 2009 Dear Colleagues, Since I wrote you in early December about the need to be financially prudent in these uncertain economic times, a number of you have asked me what, if any, changes we foresee making here at UT South…

Dr. Parada Elected to the National Academy of Sciences May 03, 2011 To the UT Southwestern Community: Please join me in congratulating our colleague, Luis F. Parada, Ph.D., Chairman of the Department of Developmental Biology at UT Southwestern Medical Center, who was elected this morning…