HIPAA - Health Insurance Portability and Accountability Act of 1996

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Chapter & Policy/Procedure Name (click title to view chapter)	Forms
1. Uses and Disclosures of Protected Health Information	1A Notice of Directory Listing
	1B Provider Request for PHI
	1C Payer Request for PHI
	1D Research Request for PHI
	1E Disclosure of PHI for Abuse, Neglect and Domestic Violence
	1F Notice of Disclosure of PHI (page 2 of form 1E)
	1G Disclosure of PHI for Law Enforcement
	1H Oversight and Regulatory Request
	1I Judicial or Legal Requests for PHI
	1J Disclosure of PHI About the Deceased
	1K Authorization for Use or Disclosure of PHI --- OR --- All Purpose Form
	1L Authorization to Release PHI --- OR --- All Purpose Form
2. Minimum Necessary Standard for Protected Health Information	None
3. De-Identification of Protected Health Information	None
4. Limited Data Set for Protected Health Information	None
5. Verification Requirements for Use and Disclosure of PHI	None
6. Patient’s Right to Notice of Privacy Practices	6A Acknowledgment of Receipt 6A Reconocimiento de Recibo --- OR --- All Purpose Form
7. Patient’s Right to Access of Protected Health Information	Privacy Access Request
	7A Patient Request for Access to Protected Health Information --- OR --- All Purpose Form
	7B Response to Request for Access to Protected Health Information --- OR --- All Purpose Form
	7C Response to Denial of Access Form
8. Patient’s Right to Request Privacy Protection	Privacy Access Request
	8A Request to Restrict Uses and Disclosures of PHI --- OR --- All Purpose Form
	8B Response to Request to Restrict Uses and Disclosures of PHI
	8C Request for Confidential Communications --- OR --- All Purpose Form
	8D Response to Request for Confidential Communications
9. Patient’s Right to Amend Protected Health Information	Privacy Access Request
	9A Request to Amend PHI --- OR --- All Purpose Form
	9B Response to Request to Amend PHI
	9C Extension of Time to Respond to Request to Amend PHI
10. Patient’s Right to an Accounting of Disclosures of Protected Health Information	Privacy Access Request
	10A Request for Accounting of Disclosures of PHI --- OR --- All Purpose Form
	10B Response to Request for Accounting of Disclosures of PHI
	10C Extension of Time to Respond to Request for Accounting of Disclosures of PHI
	10D Accounting of Disclosures
11. Patient’s Right to Assign a Personal Representative and Rights of Emancipated Minors	All Purpose Form
12. Privacy Records and Compliance Reports	None
13. Polk County BoCC Administrative Actions Regarding Protected Health Information	Privacy Access Request
	10A Request for Accounting of Disclosures of PHI --- OR --- All Purpose Form
	10B Response to Request for Accounting of Disclosures of PHI
	10C Extension of Time to Respond to Request for Accounting of Disclosures of PHI
	10D Accounting of Disclosures
14. Business Associates	None
15. Miscellaneous	15A Separated Employee Confidentiality Statement
15. Miscellaneous	15B EMS Separated Employee Confidentiality Statement