HIPAA Forms

As of 4-14-03, the Federal government has required medical practices to take steps to limit the use and disclosure of ‘protective health information’. Civil and criminal penalties range from $25,000 to $250,000 for non-compliance. It is required that physicians make a reasonable effort to provide each patient with a Notice of Privacy, and have them sign and acknowledgement receipt of this notice.

Our Notice of Privacy Form is the most comprehensive and compliant NPP form available – designed by one of the leading consultants in the industry. Our form has a peel off label, which is attached to the form, signed by the patient, and then affixed to the patient's medical chart. This assures you that the patient has received the NPP.

Our NPP is the most comprehensive in the industry. This means we have listed numerous uses and disclosures that cover every practice, whether you are a Pediatrician, Family Practice, Cardiologist, etc. By listing all these uses and disclosures in the NPP, we have eliminated the need of obtaining signed authorization forms from your patients in the future. This will save your practice time and money!

Our forms are stocked in our warehouse and ready to be shipped today! Don’t wait! The time to comply is now!

Notice of Privacy Practices
You must provide written Notice of Privacy Practices to patients on or before the first encounter and to other persons upon request. This Notice notifies the patient of all uses and disclosures which you may make of his or her protected health information ("PHI").

Written Acknowledgement of Receipt of Notice of Privacy Practices
You must obtain written acknowledgement that the patient received the Privacy Notice or must document the reasons why a written acknowledgement could not be obtained.

Authorization
PHI may be used and disclosed without Authorization only for the purposes specifically listed in the Privacy Regulations. All other uses and disclosures require an Authorization.

Verification
Except for disclosure to persons involved in the patient's care and for notification purposes, you must verify the identity of anyone requesting protected health information if that person is not already known to you

Request to Inspect Protected Health Information
Under HIPAA's Privacy Regulations, patients and their personal representatives have the right to review and make copies of the patient's PHI.

Request for an Accounting of Disclosures of Health Information
Every patient has the right under HIPAA's Privacy Regulations to receive an "accounting" of all uses and disclosures made of their protected health information. For documentation purposes, these requests should be made in writing. Request that all patients complete this form when requesting an accounting of disclosures.

PHI Disclosure Log
All patients have the right under the HIPAA Privacy Regulations to receive an accounting of all disclosures of their protected health information, with certain exceptions. Use this form to provide patients with the accounting of disclosures made for the requested time period.

Request for Restrictions on Uses and Disclosures of Protected Health Information
Under the HIPAA regulations, patients have the right to restrict uses and disclosures of their protected health information made for (1) treatment, payment or health care operations and (2) to family or others involved in the patient's care or for notification purposes. Have patients complete this form when requesting restrictions. Note that you are not required to agree to the restriction.

Request for Amendment to Protected Health Information
HIPAA's Privacy Regulations give patients the right to request that their protected health information be amended if they believe the information is inaccurate or incomplete. Have patients complete this form when requesting an amendment to their protected health information.

Denial of Request to Amend Protected Health Information
HIPAA's Privacy Regulations give patients the right to request that their protected health information be amended if they believe the information is inaccurate or incomplete. You may deny the request under certain circumstances, but must inform the patient in writing of your denial and must set forth the basis for the denial. Use this form to inform patients of your denial of their request to amend their protected health information.

Request for Confidential Communications
Patients have the right to request that you send them communications regarding their protected health information by alternate means or at an alternate address. Have patients complete this form to request confidential communications.

Privacy Complaint Form
Patients who believe their privacy rights with respect to their protected health information have been violated have the right to complain either to you or to the Secretary of the Department of Health and Human Services. You must provide a process for patients to make complaints and must document all complaints and their disposition, if any. Have patients who have a complaint about your privacy practices complete this form.

PHI Tracking Log
To keep track of HIPAA information being reviewed, released, etc. This form can be used by staff as a quick reference to activity that has occurred as it relates to each patientís record.

Employee Training Record
HIPAA training is mandated. Each employee is required to attend HIPAA educational sessions. Keep this form in each employeeís personnel folder and record each time the employee attends any HIPAA educational workshops, seminars, etc. whether in-house or off-site.

Practice Training Record
All training efforts that the practice makes related to employee training should be documented in your HIPAA policy & procedure manual. Use this form to track all educational initiatives. Be sure each employee signs the attendance sheet for each session. Keep handouts, materials, etc. utilized during the session attached to the form.