College of Medicine

 1.   Confidentiality Forms

Confidentiality Statement (PDF)
    On-line form with Registration

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

Group Observation Roster (PDF)
    On-line Form

 2.   Patient Rights Forms

Notice of Privacy Practices
    En Español

Acknowledgement of Receipt of NPP
    En Español

Authorization to Use or Disclose Protected Health Information For routine Release of Information (PDF)
    On-line form

Authorization for Electronic Communication
For Release of Information by E-mail, Video-Conference, or Audio-Conference (PDF)
On-line form
     Alert for Electronic Communications

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

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

Request for Amendment of a Medical Record (PDF)
Response to Request for Amendment

Request for Accounting of Disclosures (PDF)

 3.   Disclosure Forms

Fax Cover Sheet (PDF sample: modify as needed)

Certification of Authenticity (PDF)
(to certify authenticity of copied records)

Disclosure Tracking Log Form
(see Accounting for Disclosures: paper forms should only be used if on-line system is down )

 4.   Incident and Complaint Forms

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

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

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

 5.   Record Storage and Destruction Forms

Medical Record Storage Inventory

Medical Record Destruction Log

UF Record Disposition Request