Privacy Practices
Request and Response
- Authorization Revocation Form [pdf]
- Authorization to Use or Disclose PHI [pdf]
- Do Not File Insurance Waiver Form [pdf]
- Request to Access PHI [pdf]
- Request for Accounting of Disclosures [pdf]
- Request for Alternate Means of Confidential Communications [pdf]
- Request for Correction or Amendment of PHI [pdf]
- Response to Individual Request to Inspect and Copy Records [pdf]
- Request for Protected Health Information [pdf]
Documents
- Confidentiality Agreement [pdf]
- Notice of Privacy Practices (English) [pdf]
- Notice of Privacy Practices (Spanish) [pdf]
- Fax cover sheet [doc]
- Receipt of Notice of Privacy Practices (English) [pdf]
- Receipt of Notice of Privacy Practices (Spanish) [pdf]