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 (English)
    Notificacion Conjunta Sobre Practicas de Privacidad (En Español)

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

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

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

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

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

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

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

Request for Accounting of Disclosures (PDF Form)

 3.   Disclosure Forms

Fax Cover Sheet (PDF sample: modify as needed)

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

 4.   Incident and Complaint Forms

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

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

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

 5.   Record Storage and Destruction Forms

Medical Record Storage Inventory

Medical Record Destruction Log

UF Record Disposition Request