HIPPA Forms Page

HIPAA Forms

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Form Name:	Description
Description of HIPAA Forms MS Word Version	This document explains the rest of the forms available below
HIPAA Privacy Notice MS Word Version	This document is a sample Privacy Notice for employers to review and customize for their organization. This notice also details the procedures employees are to follow to file a complaint. This notice is to be placed where all employees can view it on a daily basis.
Privacy Office Job Description MS Word Version	This document is a detailed job description outlining the official functions this individual should be performing on a daily basis. There is also verbiage that should be added to the Privacy Officer’s job description, as well as to any other individual’s job description that has access to protected health information.
Contact Person Provision Job Description Insert MS Word Version	This provision may be inserted in the job description of the employee assigned the duties of contact person under the HIPAA Privacy Rule. In a small plan, this person will likely also be the privacy officer.
Individuals Whose Duties Include Access to Health Information MS Word Version	This provision should be inserted in the job description of any employee who will have access to protected health information.
HIPAA Authorization to Disclose Health Information MS Word Version	This document is to be completed when a covered entity must obtain an individual’s written authorization for any use or disclosure of protected health information that is not for treatment, payment or health care operations or otherwise permitted or required by the Privacy Rule. Examples of disclosures that would require an individual’s authorization includes disclosures to a life insurer for coverage purposes, disclosures to an employer of the results of a post-offer physical or lab test, or disclosures to a pharmaceutical firm for their own marketing purposes.
Business Associate Contract MS Word Version	This contract is to be used when a covered entity uses a contractor or other non-workforce member to perform “business associate” services or activities. HIPAA requires that the covered entity include certain protections for the information in a business associate agreement/contract. This contract details specific written safeguards on the individually identifiable health information used or disclosed by its business associates.
US Department of Health and Human Services HIPAA Summary Word Version	This pamphlet, created by the United States Department of Health and Human Services, is a summary of key elements of the Privacy Rule including those covered and what information is protected, as well as the use and disclosure of protected health information. Because it is an overview of the Privacy Rule, it does not address every detail of each provision, but does contain links to detailed guidance documents.

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