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HIPAA PRIVACY PROGRAM


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


FORM or AUTHORIZATION

PURPOSE
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.  Does not include authorization to copy/disclose mental health records.
Mental Health Records Authorizes UCMC to disclose mental health information.  Instructions can be found here.
General Authorization - Use and Disclose Health Information General patient authorization to use and disclose PHI.  (En Espanol)
Disclose to University of Chicago Administration Allows UCMC 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 UCMC or assisting with transition back to campus, classes, relevant community services and UofC housing.
Trusted Requestor (Request for PHI for Uses Other Than Treatment or Payment) Use this form when requesting PHI for uses other than treatment or payment.
Fax Cover Sheet Includes approved language for fax cover sheets.
Notice of Privacy Practices Acknowledgement Form Use this form when a patient is given a Notice of Privacy Practices. Collect the signed Acknowledgement Form from the patient and forward to Health Information Management (Medical Records), AMB WB20 (MC 0978).
Billing Information Use this form when the patient or the patient's representative requests over the telephone that the billing information be sent to the address on record.
Disclosure to University of Chicago Used by UCMC patients to assist with the process of obtaining their medical records from non-UCMC providers.
Education 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.
Estate
Executor/Administrator of the estate of the Patient named allows the UC Organizations to disclose the Patient's health information.
Observers
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.
Schools
Authorizes the UC OHCA to disclose child's/ward's health information to his/her school. (En Espanol)
Disability Determination
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.

Employee Benefits Office
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.
Employer
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.
Family Members - FMLA
Individual's family member is seeking Family and Medical Leave Act leave ("FMLA") and his/her employer has asked UCMC complete an FMLA form. This form authorizes UCMC to complete the FMLA form and give it to individual's family member or send it to his/her employer.
Workers' Compensation
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.



LAW ENFORCEMENT FORMS

FORM PURPOSE
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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