The University of Texas Health Science Center at San Antonio, Office of Regulatory Affairs and Compliance, Compliance Office 210-567-2014, Compliance Line 1-800-500-0333
REGULATORY AFFAIRS & COMPLIANCE HOME POLICIES & PROCEDURES COMPLIANCELINE CONTACT INFORMATION UNIVERSITY HOMEPAGE
HIPAA Compliance Program

 

 

Patient Rights Under HIPAA

Patient Privacy Policies
and Procedures

Patient Privacy Forms

Training

Business Associates

Disciplinary Guidelines

IRB Homepage (Research)

Selected Links

Office of Regulatory Affairs & Compliance Homepage

Help

             

 

Link to HIPAA Compliance homepage

Index of Patient Privacy Forms

 


  • Accounting of Disclosures of Protected Health Information - MS Word or .pdf

  • Acknowledgement of Receipt of Notice of Privacy Practices
            English: MS Word or .pdf
            Spanish: MS Word or .pdf

  • Amendment Denial Letter - MS Word or .pdf

  • Confidentiality/Security Acknowledgement - MS Word or .pdf

  • Consent and Agreement for Treatment/Dental School - MS Word or .pdf

  • Consent for Photography - MS Word or .pdf

  • Data Use Agreement - MS Word or .pdf

  • Dental School E-mail Authorization Agreement - MS Word or .pdf

  • E-mail Authorization Agreement - MS Word or .pdf

  • Facsimile Cover Sheet - MS Word

  • Letter for Misdirected Fax - MS Word or .pdf

  • Patient Authorization for Release of Health Records to External Parties
            English: MS Word or .pdf
            Spanish: MS Word or .pdf

  • Patient Authorization for Release of Health Records for Purposes other than Treatment and UTHSCSA Education - MS Word or .pdf

  • Office of Development - Patient Authorization Form for Use of Health Records for Purposes other than Treatment and UTHSCSA Education - MS Word or .pdf

  • Release Form - MS Word or .pdf

  • Request for Accounting of Disclosures - MS Word or .pdf

  • Request for Amendment of Health Information - MS Word or .pdf

  • Request for Confidential Communications Regarding Medical Information - MS Word or .pdf

  • Restriction Request Form - MS Word or .pdf

  • Revocation of Authorization to Release Protected Health Information - MS Word or .pdf

 

       

Top of Page | Patient Rights Under HIPAA | Patient Privacy Policies & Procedures | Patient Privacy Forms
HIPAA Task Force | Training | Business Associates | IRB Homepage (Research)
Selected Links | Office of Regulatory Affairs & Compliance | Help | University Homepage

Links provided from Health Science Center pages to other websites do not constitute or imply an endorsement of those sites, their content, or products and services associated with those sites.

© 2002-2003 UTHSCSA HIPAA Compliance Program
Created 04 December 2002. Updated 31 October 2006.
Comments or questions about this website: knight@uthscsa.edu

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