regulation of Medicine

toolkit

The HIPAA Toolkit

Sample forms

Access Denial Letter

This template will help you in the event you need to deny a request for access to PHI. 

Download here.

Access to Protected Health Information

This form will help patients request their health information. 

Download here.

Amendment of Protected Health Information

Use this form when a patient wants to request a change to their health information. 

Download here.

Authorization

This is a form patients may use to authorize the disclosure of their health information. 

Download here.

Certification of Assurances

Use this form for satisfactory assurances statement for judicial administrative proceedings. 

Download here.

Complaint Regarding Uses/Disclosures of Protected Health Information

This form can be used to file a complaint regarding privacy policies and procedures. 

Download here.

Data Use Agreement

Use this form as an agreement between your practice or facility and any data recipient. 

Download here.

HIPAA Breach Analysis Tool

This tool will help you determine whether a breach has occurred at your practice or facility. 

Download here.

HIPAA Breach Notification Letter

Use this letter to inform patients that their PHI has been breached. 

Download here.

HIPAA Privacy Breach Log

Use this log to keep track of HIPAA breaches. 

Download here.

Notice of Privacy Practices

Use this to notify patients of your privacy practices. 

Download here.

Request for Access to Protected Health Information

Request form for patients who would like to access protected health information. 

Download here.

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. 

Download here.

Request for Communication by Alternative Means/Location

Use this form when a patient needs to request an alternate means for communicating PHI. 

Download here.

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. 

Download here.

Sample Letter to Patient Re Subpoena

Use this sample letter to inform patients that their PHI has been subpoenaed. 

Download here.

Sample Letter to Third Party Re Subpoena

Use this letter to respond to an entity that has subpoenaed your patient's records. 

Download here.

Disclaimer

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.