Forms & Templates

• Sample Disclosure Tracking Log
• Sample Request for Accounting of Disclosures
• Sample Reports of Disclosures to Third Parties

Acknowledgement for Receipt of Notice of Privacy Practices

• Authorization for Disclosure of Medical Information (General Purpose)
• Authorization for Disclosure of Medical Information (General Purpose; Spanish)
• Authorization for Disclosure of Medical Information in Presentation or Publication
• Authorization for Disclosure of Medical Information in Presentation or Publication (Spanish)
• Authorization for Use or Disclosure of Medical Information for Marketing or Fundraising
• Authorization for Use or Disclosure of Medical Information for Marketing or Fundraising (Spanish)

• Business Associate Agreement
• Business Associate Agreement – UW serving as Business Associate
• Certification that PHI Destroyed or Destruction Infeasible

• Database Decision Tool: This tool is used to determine if a database that is used for research purposes must be registered with the UW–Madison HIPAA Privacy Officer.
• Database Registration and Preparatory to Research Certification for Database Custodian: This form is used to register a database with the UW–Madison Privacy Officer and, when applicable, for the database custodian to certify use of the database in preparation of a research protocol.

• Data Use Agreement (DUA) for Disclosure of a Limited Data Set (LDS)
• Data Use Agreement (DUA) for Receipt of a Limited Data Set (LDS)

Fax Transmission Cover Sheet

ALTERNATIVE CONFIDENTIAL COMMUNICATIONS

• Alternative Confidential Communication Request Form
• Letter Accepting Individual’s Request for Alt. Confidential Communications
• Letter Denying Individual’s Request for Alt. Confidential Communications

AMENDMENT OF PROTECTED HEALTH INFORMATION

• Sample Request for Amendment of Health Information
• Sample Request for Notification of Amendment
• Sample Letter Notifying of Need for 30 Day Extension
• Sample Letter Accepting Amendment
• Sample Letter Denying Amendment
• Sample Letter Responding to Statement of Disagreement

INSPECTION AND COPYING OF PROTECTED HEALTH INFORMATION

• Sample Letter Notifying of Need for 30 Day Extension
• Sample Letter Denying Request to Obtain a Copy of PHI

RESTRICTIONS ON USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION

• Request for Restrictions on Use/Disclosure of PHI
• Sample Letter of Approval of Request for Restrictions
• Sample Letter of Denial of Request for Restrictions

• Certification for Activities Preparatory to Research: This certification must be signed prior to using PHI in the preparation of a research protocol.
• Certification for Research on the Protected Health Information of Decedents: This certification must be signed when the research, or a distinct part of the research, uses only the protected health information of decedents.

Data Use Agreement: This agreement must be completed before receiving or disclosing a Limited Data Set (“LDS”).

• Data Transfer and Use Agreements: Use these forms to disclose or receive an LDS from an external entity.
• Internal Data Use Agreement for Use or Disclosure of a Limited Data Set: This internal data use agreement must be signed when a UW–Madison employee receives a limited data set from within the UW HCC or UW ACE.