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SUNY Downstate Medical Center

University Physicians of Brooklyn, Inc.

UPB Polices and Forms

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 Policies:

Policy Name (PDF)
Accounting of Disclosures
Alcohol & Substance Abuse Information
Business Associate Agreement - UPB
Compliance & Enforcement
Compliance Training
De-Identification of Information
Designated Record Sets
Facility Directory
Faxing Patient Information
Fundraising Activities
HIV Information
Mental Health Information
Minimum Necessary Guidelines
Notice of Privacy Practices
Patient Requests for Access
Patient Requests for Additional Privacy Protections
Patient Requests for Amendment
Personal Representatives
Privacy Rights of Minors
QA Records
Safeguards for Protected Health Information
Workforce Confidentiality
Telephone Requests for Patient Information
Use of Limited Data Sets
Uses & Disclosures for Treatment, Payment & Healthcare Operations
Uses & Disclosures Not Requiring Patient Authorization
Uses & Disclosures of Decedent Information
Uses & Disclosures Requiring Patient Authorization
Uses & Disclosures to Individuals Involved in Care & for Notification Purposes
Verification of Identity

UPB Forms:

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


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