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HIPAA - Health Insurance Portability and Accountability Act

HIPAA Privacy Policies & Procedures

All of the policies below have been approved and may not be altered in any manner, except to customize the Procedure section for the respective departmental area.  To customize the Procedure section, an attachment must be created and appended to the department's internal policy.  The Procedure section is dependent upon each department's unique operating structure and should be customized accordingly.

Policies & Procedures

HIPAA Privacy Policies
POLICY NAME
POLICY PDF FORM / ATTACHMENT
Accounting of Disclosures PDF logo

Patient Request Accounting of Disclosures Form

Accounting of Disclosures HIM Templates

Alcohol and Substance Abuse Information (Special Category)* PDF logo Alcohol and Substance Abuse NOP
Business Associate Agreements PDF logo BAA Template
Compliance and Enforcement PDF logo  
Compliance (& HIPAA) Training PDF logo Course Requirement Matrix
Covered Entity Designation PDF logo  
De-Identification of Information PDF logo  
Designated Record Set PDF logo  
Facility Directory PDF logo Facility Directory Form
Faxing Patient Information PDF logo Fax Cover Page
Fundraising Activities PDF logo Fundraising Opt-out Form
HIV Related Information (Special Category)* PDF logo NOP For HIV Info
Marketing Activities PDF logo Marketing Authorization Form
Mental Health Information (Special Category)* PDF logo NOP for Mental Health Info
Minimum Necessary Guidelines PDF logo  
Notice of Privacy Practices* PDF logo NOP Acknowledgement Form
Patient Requests for Access PDF logo

Patient Access Authorization Form

Patient Access HIM Templates

Patient Requests for Additional Privacy Protections PDF logo

Out of Pocket Restriction Form

Patient Requests Addtnl Privacy Form / Template

Patient Requests for Amendment PDF logo

Patient Requests Amendment Form

Patient Requests Amendment HIM Templates

Personal Representatives PDF logo  
Privacy Rights of Minors PDF logo  
Quality Assurance PDF logo  
Safeguards for Protected Health Information PDF logo  
Sale of Protected Health Information PDF logo Patient Authorization for Sale of PHI
Short Notice of Privacy for Healthcare Events PDF logo Short NOP with Patient Receipt Log
Student Immunization Records PDF logo  
Telephone Requests for Patient Information PDF logo  
Use of Limited Data Sets PDF logo Data Use Agreement Template
Use & Disclosure for Research Purposes PDF logo

Certification for Reviews Preparatory to Research

Certification for PHI of Decedents

HIPAA Waiver of Authorization

Subject Recruitment Authorizations

Sponsor Contract Privacy Provisions

Uses & Disclosures for Treatment, Payment & Healthcare Operations PDF logo  
Uses & Disclosures Not Requiring Patient Authorization PDF logo  
Uses & Disclosures of Decedent Information PDF logo  
Uses & Disclosures Requiring Patient Authorization PDF logo Patient Authorization Form
Uses & Disclosures to Individuals Involved in Care & for Notification Purposes PDF logo  
Verification of Identity PDF logo  
Workforce Confidentiality PDF logo Workforce Confidentiality Attestation


*For translated versions of this notice, please visit http://www.downstate.edu/policy/patient.html
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