Employees : HIPAA Forms & Attachments

HIPAA Forms & Attachments

Please find below all the forms and documents to be used for all HIPAA-related matters at the University of Miami. If you have any questions concerning any of these forms or documents, please contact us at 305-243-5000 or at hipaaprivacy@med.miami.edu

Notice of Privacy Practices & Acknowledgement Form

If you need to order Notices of Privacy Practices or any other HIPAA forms, you may do so in the Ariba system via Print Farm, our exclusive vendor for the current Notice of Privacy Practices. For more information about these notices, please view Frequently Asked Questions about the new Notice.

English

Notice of Privacy Practices (English)
Effective Date: 09/20/2013

Acknowledgement of Receipt (English)
Revision: 09/20/2013
ID#: D3900001E

Spanish

Notice of Privacy Practices (Spanish)
Effective Date: 09/20/2013

Acknowledgment of Receipt (Spanish)
Revision: 09/20/2013
ID#: D3900001S

Reference Documents

HIPAA Fax Cover Sheet
University of Miami HIPAA Fax Cover Sheet

HIPAA Email Disclaimer
University of Miami HIPAA Email Disclosure Warning

Non-Objection Certification
Certificate of Non-Objection and Compliance with HIPAA

Subpoena Quick Reference
Is the subpoena you received HIPAA-compliant?

Quick Reference Guide For 3rd Party Authorization
Is the 3rd Party Authorization HIPAA-compliant?

Non-HIPAA Forms

Consent for Medical Treatment AND Conditions of Admission

Consent and Conditions (English)
Revision: 05/13/2014

Consentimiento y Condiciones (Spanish)
Revision: 05/13/2014

HIPAA Forms & Related Documents

Report a HIPAA Incident
HIPAA Incident Report Form
(Loss, Theft, Inappropriate Access, Disclosure of PHI)

Release of Medical Records / Access to Health Information

Attachment 19 (English)
Request for Access to Health Information
Revision: 09/24/2014
ID#: D3900018E

Adjunto 19 (Spanish)
Petición de Aceso a Historial Médico
Revision: 09/24/2014
ID#: D3900018S

3rd Party Authorizations

Attachment 46 (English)
Authorization for 3rd Party Disclosure
Revision: 09/11/2013 - Fillable Form
ID#: D3900052E

Adjunto 46 (Spanish)
Autorización para Divulgación a 3.as Personas
Revision: 06/03/2014
ID#: D3900052S

Atachman 46 (Creole)
Otorizasyon pou Divilgasyon Enfòmasyon ba Twazyèm Pati
Revision: 12/8/2008
ID#: D3900052C

Photo Authorization (English)
Authorization to Release Protected Health Information and Photographs for Publication
Revision: 3/5/2009 - Fillable Form
ID#: D3900055E

Photo Authorization (Spanish)
Autorización/Cesión de Fotografías o Grabaciones de Audio/Video
Revision: 4/28/2009 - Fillable Form
ID#: D3900055S

Other HIPAA Forms

Provider to Provider
Provider to Provider Release for Treatment Purposes
Revision: 8/7/2009 - Fillable Form

Attachment 33 - Request for Amendment
Request for Amendment of Health Information
Revision: 11/21/2008 - Fillable Form
ID#: D3900031E

Attachment 45 - Accounting for Disclosure
Accounting for Disclosure Form
Revision: 8/7/2009 - Fillable Form
ID#: D3900048E

Attachment 41 - Request an Accounting
Request for an Accounting of Disclosures of Health Information
Revision: 11/21/2008
ID#: D3900039E

Attachment 13 - Alternative Communications
Request for Communications at Alternative Locations or by Alternative Means
Revision: 11/21/2008
ID#: D3900012E

Attachment 6 - Restriction
Request for Restrictions on Use and Disclosure of Health Information
Revision: 11/21/2008
ID#: D3900005E

Attachment 6HP - Restrictions on Disclosure to your Health Plan
Request for Restrictions on Disclosure of Health Information to your Health Plan for a Health Care Service for which you PAY IN FULL OUT OF POCKET
Revision: 09/11/2013
ID#: D39000061E

Anexo 6HP - Restricciones de información a su Plan de salud
Solicitud de restricciones a la revelación de información relativa a la salud a su Plan de salud para el Servicio de atención de la salud por el cual usted PAGA DE SU BOLSILLO EL PAGO COMPLETO
Revision: 09/11/2013
ID#: D39000061S

Attachment 18 - Facility Directory Form (Inpatient Hospital Facilities Only) 
Revision: 11/21/2008
ID#: D3900017E

Attachment 44 - Complaint Form
Revision: 6/10/2011
ID#: D3900042E

Attachment Response Letters

Attachment 20
Letter to Patient Denying the Request for Access in Partial
Revision: 11/21/2008
ID#: D3900019E

Attachment 21
Letter to Patient Denying the Request for Access in Full
Revision: 11/21/2008
ID#: D3900020E

Attachment 22
Letter to Patient Regarding Provision of Access in Full
Revision: 11/21/2008
ID#: D3900021E

Research Forms

These and other HIPAA-related research documents may be found at the Human Subjects Research Office HIPAA page.

Form B (English)
Authorization to Use and Disclose Health Information for Research
ID#: D3901001E

Forma B (Spanish)
Autorización para el Uso y la Divulgación de Información de Salud para Investigación
ID#: D3901001S

Attachment 45 - Accounting for Disclosure
Accounting for Disclosure Form
Revision: 8/7/2009
ID#: D3900048E