The below forms, templates, and agreements are categorized as general and research. The general items can be used in all situations, while the research items can only be used in research situations.
General
This is an accordion element with a series of buttons that open and close related content panels.
Accounting of Disclosures
Acknowledgement for Receipt of Notice of Privacy Practices
Authorizations
- 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 Agreements
Database Registration
- 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 Agreements
Fax Cover Sheet Template
Patient/Research Participant Requests
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
Research
This is an accordion element with a series of buttons that open and close related content panels.
Certifications
- 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 Agreements
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.