The University of Arizona

HIPAA Forms

Form A: Authorization for Release of Medical Information (PDF)
Form B: HIPAA Authorization Template (PDF)
Form C: Denial of a Request for PHI (PDF)
Form D: Request for an Accounting of Disclosures of PHI (PDF)
Form E: Accounting of Disclosures of PHI (Documentation Form) (Word)
Form F: Accounting of Disclosures of PHI for Research (Word)
Form G: Accounting of Disclosures of PHI (Internal Tracking Form) (PDF)
Form H: Request for an Amendment of PHI (PDF)
Form I: Template Letter: Denial of PHI Access (Word)
Form J: Template Letter: Delay in Processing Request to Amend PHI (Word)
Form K: Template Letter: Denial of Request to Amend PHI (Word)
Form L: Notice of Privacy Practices (Checklist) (PDF)
Form M: Template Letter: Request for Confidential Communications/Restriction (PDF)
Form N: Fax Cover Sheet (PDF)
Form O: Data Use Agreement Request (PDF)
Form P: De-Identification of PHI (PDF)
Form Q: Is it PHI? (PDF)
Form R: Acknowledgment of Notice of Privacy Practices Receipt (Word)
Form S: Secure Media Destruction Record (Word)