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Business Associate Agreement - University of Chicago Medical Center
Business Associate Agreement - University


Copy Medical Records For a patient's request to copy medical records located in the Health Information Management department.  Instructions and additional information can be found here
Mental Health Records Authorizes UCM to disclose mental health information.  Instructions can be found here.
General Authorization - Use and Disclose Health Information General UCM patient authorization to use and disclose PHI.
Disclosure to Designated Individuals
Allows UCM clinic, billing and finance staff to disclose patient appointment and billing information for health care purposes to those individuals assisting in the patient's affairs to help facilitate services.
Request for Amendment of PHI
Use this form when a UCM patient believes there is an error and would like to request an amendment to the information in the medical record.
Patient Request for Restriction of PHI Form
This form is used by patients to request a restriction on the use or disclosure of protected health health information to a specific person, organization, or health plan.
Disclosure to University of Chicago Administration Allows UCM to disclose health information of University of Chicago students to the UofC Dean on Call, Dean's Office, and/or UofC Housing Department for assisting with care at UCM or assisting with transition back to campus, classes, relevant community services and UofC housing.
Analytics Core Request System (ACReS)
Click this link for the Analytics Core Request System (ACReS) to make a request for data. More information about the Analytics Core and Data Governance can be found here.
Fax Cover Sheet Use as a fax cover sheet.
Notice of Privacy Practices Acknowledgement Form Use this form when a patient is given a UCM Notice of Privacy Practices. Collect the signed Acknowledgement Form from the patient and forward to Health Information Management (Medical Records), AMB WB20 (MC 0978).
Disclosure to University of Chicago Used by UCM patients to assist with the process of obtaining their medical records from non-UCM providers.
Education and/or Publication
Allows the UCM to use and disclose the health information listed below for the following purpose(s): create and present one or more case study(ies) about individual's health information, create and present one or more presentation(s) that includes individual's health information, create and publish one or more article(s) or other writing(s), and other purposes that the user can list.
Executor/Administrator of the estate of the Patient named allows the UCM to disclose the Patient's health information.
Allows the UCM to disclose the health information listed for the purpose of allowing a particular individual to observe clinical care in process. This person is NOT a student in an educational program sponsored by any UCM.
Authorizes the UCM to disclose child's/ward's health information to his/her school.
Disability Determination
Allows the UCM to disclose the health information for the following purposes: confirm the need for leave of absence, determination of disability, or other identified by the user.

Employee Benefits Office
Used by UCM when having difficulty with patient's insurance company paying the bill for services rendered. UCM finds that a patient's employee benefits office can assist in working with the insurance company. This form permits UCM to share the protected health information to the employee department of the employer who provides patient health insurance plan.
This allows the UCM to disclose health information for the following purpose(s): confirm the need for leave of absence, probable cause for drug/alcohol abuse, pre-employment evaluation/screening, worker's compensation evaluation and follow up treatment, confirm fitness for duty/modified duty.
Family Members - FMLA
Individual's family member is seeking Family and Medical Leave Act leave ("FMLA") and his/her employer has asked UCM complete an FMLA form. This form authorizes UCM to complete the FMLA form and give it to individual's family member or send it to his/her employer.
Worker's Compensation
This allows the UCM to disclose PHI for Worker's compensation review and claim processing and adjudication, or other purpose identified by the user.


Law Enforcement Request for PHI
Chicago Police Department's Request Form for PHI.
Law Enforcement - Verification About Patient-Victim
Use this form to document law enforcement's immediate need of information about a patient-victim.  This form is to be completed by any physician/licensed healthcare provider treating the patient.

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