HIPAA Compliance Program, Compliance Office 210-567-2014, Compliance Line 1-877-507-7317
 

Index of Patient Privacy Forms

 
Accounting of Disclosures of Protected Health Information MS Word .pdf
English:
Spanish:
Acknowledgement of Receipt of Notice of Privacy Practices
MS Word
MS Word
.pdf
.pdf
Amendment Denial Letter MS Word .pdf
Confidentiality/Security Acknowledgement MS Word .pdf
Consent and Agreement for Treatment/Dental School MS Word .pdf
Consent for Photography MS Word .pdf
Data Use Agreement MS Word .pdf
Dental School E-mail Authorization Agreement MS Word .pdf
E-mail Authorization Agreement MS Word .pdf
Facsimile Cover Sheet MS Word .pdf
Health Plan Restriction Request MS Word .pdf
Letter for Misdirected Fax MS Word .pdf
English:
Spanish:
Patient Authorization for Release of Health Records to External Parties
MS Word
MS Word
.pdf
.pdf
Patient Authorization for Release of Health Records for Purposes other than Treatment and UTHSCSA Education MS Word .pdf
Office of Institutional Advancement Patient Authorization Form MS Word .pdf
Patient Release Form MS Word .pdf
Request for Accounting of Disclosures MS Word .pdf
Request for Amendment of Health Information MS Word .pdf
Request for Confidential Communications Regarding Medical Information MS Word .pdf
Restriction Request Form MS Word .pdf
Revocation of Authorization to Release Protected Health Information MS Word .pdf
Visiting Clinician and Healthcare Professional Confidentiality Agreement MS Word .pdf
 
 
 
top of page