Human Resources

Health Insurance Portability and Accountability Act (HIPAA)

Listed below are the forms relating to your participation rights regarding your Protected Health Information (PHI).


Designation of Personal Representative
Use this form to designate a representative who can receive information on a health claim for you.

Individual Request for Retrictions on Use and Disclosure of Protected Health Information
Use this form to restrict use and disclosures of you PHI.

Individual Request for Confidential Communications of PHI
Use this form to request an alternative address for receipt of PHI

Individual Request to Inspect or Copy PHI
Use this form to request to review your PHI.

Individual Request to Amend or Correct a Record
Use this form to request to amend your PHI

Individual Request for Accounting of Disclosures of PHI
Use this form to request an accounting of disclosures of your PHI. This form cannot be used to request any disclosures that may have occurred prior to the compliance date of April 14, 2004.

Health Information Privacy Complaint Form
Use this form to submit a complaint regarding your rights under HIPAA.