Privacy Policy & Procedure Manual:

Forms for Operational Guidelines

All Forms, including Table of Contents

Version:
07/01/2009

Individual Forms

 1.   Confidentiality Forms

1a.

Confidentiality Statement (PDF)
    On-line form with Registration

06/01/2005
1b.

Request to Observe Patient Care (PDF)
    On-line Form

Group Observation Roster (PDF)
    On-line Form



03/01/2007

 2.   Patient Rights Forms

2a.

Notice of Privacy Practices (English)
    Notificacion Conjunta Sobre Practicas de Privacidad (En Español)

Acknowledgement of Receipt of NPP (English)
    Acuse de Recibo de la Notificación (En Español)


04/14/2003


03/01/2007
2b.

Authorization to Use or Disclose Protected Health Information - For routine release of health information
PDF Form
On-line form

01/01/2008
2c.

Authorization for Electronic Communication
For Release of Information by E-mail, Video-Conference, or Audio-Conference
PDF Form
On-line form (You will be redirected to an outside website.)
     Alert for Electronic Communications

03/01/2007
2d.

Authorization for Using PHI in Fundraising, Marketing, Publication, and Public Relations
PDF Form
On-line form
     Alert for Electronic Communications

01/01/2008
2e.

Authorization for Using De-Identified Health Information for Publication and Educational Purposes
PDF Form

New!
08/01/2008
2f.

Request for Special Privacy Protections (PDF Form)
   (Includes Request for Restrictions of PHI and
    Request for More Confidential Communications)

06/01/2005
2g.

Request for Amendment of a Medical Record
(PDF Form)

Response to Request for Amendment

06/01/2005
2h.

Request for Accounting of Disclosures (PDF Form)

06/01/2005

 3.   Disclosure Forms

3a.

Fax Cover Sheet (PDF sample: modify as needed)

06/01/2005
3b.

Certification of Authenticity (PDF Form)
(To certify authenticity of copied health records)

06/01/2005

 4.   Incident and Complaint Forms

4a.

Incident Report - Protected Health Information
PDF Form
On-line Form

07/01/2005
4b.

Incident Report - Personal Identification Information
PDF Form
On-line Form

07/01/2005
4c.

Privacy Complaint any type of information, PHI or PII (PDF Form only)

06/01/2005

 5.   Record Storage and Destruction Forms

5a.

Medical Record Storage Inventory

06/01/2005
5b.

Medical Record Destruction Log

06/01/2005
5c.

UF Record Disposition Request

 

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Confidentiality Statement!!

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Confidentiality Statement

UF HSC Jacksonville

(including UFJHI and UFJPI)

Report an Incident

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FAQs

Frequently Asked Questions
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