HIPAA - Faculty & Staff

Faculty & Staff Information

Forms

All forms are available for your use. Each is available to view online and then print. You will find internal use forms, like the fax cover sheet, as well as Authorization forms to use with your patients. If you have any questions or have a suggestion for a form, please contact the HIPAA Program Office at 4-9716.

Forms for your use

Authorizations For Patient Requested Releases

Authorizations Related To Patient's Employment

For more information on upcoming events and HIPAA training click here.

FORMS

IRB Forms

HIPAA Privacy Review Sample Report Form (PDF)

Fax Cover Sheet (Word Doc)

Accounting of Disclosures Downtime and Manual Tracking Form (PDF)

Notice of Privacy Practices Acknowledgement Form (PDF)

Preceptorship Confidentiality Agreement (Word Doc)

Preceptorship Proposal Form (Word Doc)

Request for PHI for Uses Other Than Treatment and Payment (Trusted Requestor Form) (PDF)

GUIDANCE - Law Enforcement Access to Patients and Information (HTML | PDF)

Verification of Law Enforcement's Immediate Need of Information About a Patient Victim Form (PDF)

Law Enforcement Official Request For Protected Health Information Form (Chicago Police Department) (PDF)

Authorization to Use and Disclose Health Information (PDF | PDF En Espanol)

General patient authorization to use and disclose PHI.

Authorization to Use and Disclose Health Information for Purposes of Education (PDF)

Allows the UC Organizations 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.

Authorization to Use and Disclose Health Information to Observers (PDF)

Allows the UC Organizations 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 UC Organization.

Authorization to Use and Disclose Student Health Information to U of C Administration (PDF)

Allows the UC Organizations to use and disclose student health information to the UC Dean on Call Dean's Office and/or the UC Housing Department for the following purpose(s): assisting the student with care at UCMC and/or assisting the student with his/her transition back to campus and classes, accessing relevant community services, and, if the student is a resident of UC housing, for housing.

AUTHORIZATIONS FOR PATIENT REQUESTED RELEASES

Medical Records Request/Authorization to Copy Health Information (PDF)

Authorization to Use and Disclose Health Information to Designated Assistants (PDF)

Authorizes the UC OHCA to disclose the following health information to the individual for the purpose of assisting with another individual's affairs, for example, billing for medical care or appointments for health care services. Examples of designated assistants include: executive secretaries, care takers.

Authorization to Use and Disclose Your Health Information and Rules that Apply To Your Duola (PDF)

By signing this form, the individual agrees that the Duola may receive health information and the individual agrees to the rules that apply to Duola.

Authorization to Use and Disclose Health Information to the Estate (PDF)

Executor/Administrator of the estate of the Patient named allows the UC Organizations to disclose the Patient's health information.

Authorization to Use and Disclose Health Information to Schools (PDF | PDF En Espanol)

Authorizes the UC OHCA to disclose child's/ward's health information to his/her school.

Telephone Request and Authorization to Copy Billing Information (PDF)

This form is used when the patient [or the patient's personal representative] requests over the telephone that billing information be sent to the address on record.

AUTHORIZATIONS RELATED TO PATIENT'S EMPLOYMENT

Authorization to Use and Disclose Health Information for Disability Determination (PDF)

Allows the UC Organizations 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.

Authorization to Use and Disclose Health Information to Employee Benefits Office (PDF)

Used by UC when having difficulty with patient's insurance company paying the bill for services rendered. UC finds that a patient's employee benefits office can assist in working with the insurance company. This form permits UC to share the protected health information to the employee department of the employer who provides patient health insurance plan.

Authorization to Use and Disclose Health Information to Employer (PDF)

This allows the UC Organizations 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.

Authorization to Use and Disclose Health Information to Family Members Regarding FMLA (PDF)

Individual's family member is seeking Family and Medical Leave Act leave ("FMLA") and his/her employer has asked the UCH complete an FMLA form. This form authorizes UCH to complete the FMLA form and give it to individual's family member or send it to his/her employer.

Authorization to Use and Disclose Health Information for Worker's Compensation (PDF)

This allows the UC Organizations to disclose PHI for Worker's compensation review and claim processing and adjudication, or other purpose identified by the user.