Health Insurance Portability and Accountability Act (HIPAA)
Listed below are the forms relating to your participation rights
regarding your Protected Health Information (PHI).
Designation
of Personal Representative
Use this form to designate a representative who can receive
information on a health claim for you.
Individual
Request for Retrictions on Use and Disclosure of Protected Health
Information
Use this form to restrict use and disclosures of you PHI.
Individual
Request for Confidential Communications of PHI
Use this form to request an alternative address for receipt of
PHI
Individual
Request to Inspect or Copy PHI
Use this form to request to review your PHI.
Individual
Request to Amend or Correct a Record
Use this form to request to amend your PHI
Individual
Request for Accounting of Disclosures of PHI
Use this form to request an accounting of disclosures of your PHI.
This form cannot be used to request any disclosures that may
have occurred prior to the compliance date of April 14,
2004.
Health
Information Privacy Complaint Form
Use this form to submit a complaint regarding your rights under
HIPAA.
