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SUNY Downstate Medical Center

University Physicians of Brooklyn, Inc.

Employee Forms and Polices

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.


UPB HIPAA Policies:

Policy Name PDF
Accounting of Disclosures PDF logo
Alcohol & Substance Abuse Information PDF logo
Business Associate Agreement - UPB PDF logo
Compliance & Enforcement PDF logo
De-Identification of Information PDF logo
Designated Record Sets PDF logo
Facility Directory PDF logo
Faxing Patient Information PDF logo
Fundraising Activities PDF logo
HIPAA Training PDF logo
HIV Information PDF logo
Mental Health Information PDF logo
Minimum Necessary Guidelines PDF logo
Notice of Privacy Practices PDF logo
Patient Requests for Access PDF logo
Patient Requests for Additional Privacy Protections PDF logo
Patient Requests for Amendment PDF logo
Personal Representatives PDF logo
Privacy Rights of Minors PDF logo
QA Records PDF logo
Safeguards for Incidental Disclosures PDF logo
Workforce Confidentiality PDF logo
Telephone Requests for Patient Information PDF logo
Use of Limited Data Sets PDF logo
Uses & Disclosures for Marketing Activities PDF logo
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
Uses & Disclosures to Individuals Involved in Care & for Notification Purposes PDF logo
Verification of Identity PDF logo

UPB HIPAA Forms:

Form Name PDF
Accounting of Disclosures - Extension Notification PDF logo
Accounting of Disclosures - Fee Estimate PDF logo
Authorization Form PDF logo
Authorization for Marketing Communications PDF logo
Business Associate Agreement - UPB PDF logo
Data Use Agreement PDF logo
Facility Directory PDF logo
Fax Cover Page PDF logo
Fundraising - Opt Out PDF logo
HIPAA Privacy Form PDF logo
Modification or Termination of Restriction PDF logo
Notice of Additional Privacy Protection Request Review PDF logo
Notice of Approval of Amendment PDF logo
Notice of Privacy Practices PDF logo
Patient Access - Extension Notification PDF logo
Patient Access - Fee Estimate PDF logo
Patient Access - Notice of Denial Letter PDF logo
Patient Access - Notice of Denial Review Letter PDF logo
Patient Amendment - Extension Notification PDF logo
Patient Amendment - Notice of Denial Letter PDF logo
Patient Request for Access to Health Information PDF logo
Patient Request for Accounting of Disclosures PDF logo
Patient Request for Additional Privacy Protection PDF logo
Patient Request for Amendment of Health Information PDF logo
Request for Patient Information PDF logo
Staff Confidentiality PDF logo


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