regulation of Medicine
The HIPAA Toolkit
August 1, 2019
Access Denial Letter
This template will help you in the event you need to deny a request for access to PHI.
Access to Protected Health Information
This form will help patients request their health information.
Amendment of Protected Health Information
Use this form when a patient wants to request a change to their health information.
This is a form patients may use to authorize the disclosure of their health information.
Certification of Assurances
Use this form for satisfactory assurances statement for judicial administrative proceedings.
Complaint Regarding Uses/Disclosures of Protected Health Information
This form can be used to file a complaint regarding privacy policies and procedures.
Data Use Agreement
Use this form as an agreement between your practice or facility and any data recipient.
HIPAA Breach Analysis Tool
This tool will help you determine whether a breach has occurred at your practice or facility.
HIPAA Breach Notification Letter
Use this letter to inform patients that their PHI has been breached.
HIPAA Privacy Breach Log
Use this log to keep track of HIPAA breaches.
Notice of Privacy Practices
Use this to notify patients of your privacy practices.
Request for Access to Protected Health Information
Request form for patients who would like to access protected health information.
Request for an Accounting of Disclosures of Protected Health Information
For patients who would like a record of all disclosures of their protected health information.
Request for Communication by Alternative Means/Location
Use this form when a patient needs to request an alternate means for communicating PHI.
Request to Restrict Use and Disclosure of Protected Health Information
This form will help patients who want to restrict certain uses and disclosures of their PHI.
Sample Letter to Patient Re Subpoena
Use this sample letter to inform patients that their PHI has been subpoenaed.
Sample Letter to Third Party Re Subpoena
Use this letter to respond to an entity that has subpoenaed your patient's records.
The information provided in this resource does not constitute legal, medical or any other professional advice, nor does it establish a standard of care. This resource has been created as an aid to you in your practice. The ultimate decision on how to use the information provided rests solely with you, the PolicyOwner.