Documents/Forms

HIPAA and Your Privacy Rights

Appendix A

• Notice of Privacy Practices (English)
• Notice of Privacy Practices (Versión en Español)

Appendix B - Forms

• Authorization of Disclosure of Information W-298
• Authorization of Disclosure of Information (Versión en Español) W-298s
• Request for Access to Protected Health Information.
• Request for Amend Protected Health Information.
• Request to Restrict Use/Disclosure of Protected Health Information.
• Breach Reporting of PII or PHI W-1701.pdf
• Breach Risk Assessment W-1702.pdf
• Breach ResolutionW-1703.pdf

Appendix C

• Guidance Specifying the Technologies and Methodologies that Render Protected Health Information Unusable, Unreadable, or Indecipherable to Unauthorized Individuals.

Appendix D

• HIPAA Privacy, Security and Breach Notification Rules.

Appendix E

• State Confidentiality Statutes
• Responsibilities Disclosure UPM

Appendix F

• SNAP ConfidentialityRegulations
• Medicaid Confidentiality Regulations