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]