Privacy Policy & Procedure Manual:

Forms for Operational Guidelines


Individual Forms
 1.   Privacy Forms
1a.

Confidentiality Statement (PDF)
    On-line form with Registration

09/23/2013
1b.

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

Group Observation Roster (PDF)
On-line Form

Volunteer Request to Observe Patient Care or Access Restricted Information (PDF)
On-line form

11/01/2013
1c.

Attestation of Compliance for Fundraising
(PDF)

On-line Form

11/01/2013
1d.

Student Data Access Request
    On-line Form only - do not complete by hand!

11/01/2013
 2.   Patient Rights Forms
2a.

Notice of Privacy Practices (English)

NPP Brochure - print on legal-sized paper

Acknowledgement of Receipt of NPP (English)
(Español)


09/23/2013




09/23/2013
2b.

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

11/01/2013
2c.

Authorizations for Electronic Communication
For Release of Identifiable Information by Video/Tele-Conference or Audio-Conference - do not use for E-mail correspondence - see below.
PDF Form
On-line Form

On-line form for Email and Other Media Use only this form to authorize Email correspondence. It can also be used for video- and audio-conferencing. You will be redirected to an outside website.)

Alert for Electronic Communications

11/01/2013
2d.

Authorization to Use or Disclose PHI in Public Activities
For Release of Identifiable Health Information for Publication, Marketing, Fundraising, Public Relations, Educational Activities Outside of UF, and Sale of PHI
PDF Form
On-line form

11/01/2013
2e.

Authorization for the Use of De-Identified Health Information for Publication and Educational Purposes
PDF Form
On-line form

11/01/2013
2f.

Requests for Special Privacy Protections (PDF Forms)
  Request for Restrictions of PHI
  Request for More Confidential Communications

11/01/2013
2g.

Request for Amendment of a Medical Record
(PDF Form)

On-line form

11/01/2013
2h.

Request for Accounting of Disclosures
(PDF Form)

11/01/2013
 3.   Disclosure Forms
3a.

Fax Cover Sheet (PDF sample: modify as needed)

09/01/2013
3b.

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

09/01/2013
 4.   Incident and Complaint Forms
4a.

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

11/01/2013
4b.

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

11/01/2013
4c.

Privacy Complaint   For any type of personal information
PDF Form
On-line form

11/01/2013
 5.   Record Storage and Destruction Forms
5a.

Medical Record Storage Inventory

11/01/2013
5b.

Medical Record Destruction Log

11/01/2013
5c.

UF Record Disposition Request

07/01/2004

UF Privacy Homepage

UF Privacy Office Contact Information
UF Privacy Policies

Health Information Privacy

Health Information Privacy Contacts
More About HIPAA

Policies & Procedures

Operational Guidelines - Health
Forms - Health
Glossary

Training

HIPAA & Privacy - General Awareness
HIPAA for Researchers
HIPAA for Visitors & Vendors
HIPAA for Fundraisers

The Red Flag Rules
FERPA Basics: Student Records
Protecting Social Security Numbers

Certificate Lookup

pointerPrint your Certificate or
Confidentiality Statement!!

Confidentiality Statement

Report an Incident

File a Complaint


UF HSC Jacksonville

(including UFJHI and UFJPI)


Access to Epic

Accounting for Disclosures

E-Mail Authorization

Honest Broker for Research

Release of Health Information

Shadowing & Volunteering

Social Security Numbers

 

FAQs

Frequently Asked Questions
HIPAA & Research at UF
Computers & Electronic Data
Emails & PHI
Disclosures Allowed By Florida Laws
HIPAA and Fundraising

Identity Theft

How it Happens, Reduce Your Risk, What To Do If You're a Victim

HIPAA Links

Search



Confidentiality Statement

Other UF Resources

UF Home
UF Directory
Health Science Center
myUFL
HSC Information Security - SPICE
UF IT Security
IRB-01