The University of Arizona

HIPAA Forms

Report Misconduct

University Ethics and Compliance Hotline:

866-364-1908

HIPAA Privacy Links

Report a Privacy Incident

Submit a Business Associate Agreement Request

HIPAA Data Reference Guide

 
Contacts:

Department Email
PrivacyOffice@email.arizona.edu

John Howard, JD
HIPAA Privacy Officer
520.621.1465

Ryan Brock, Security+
HIPAA Security Specialist
520.621.5624

Fax: 520.621.3355

Street Address:
1618 E. Helen Street
Tucson, AZ 85719

Mailing Address:
Attn: Privacy Officer
The University of Arizona
PO Box 210409
Tucson, AZ 85721

*Subscribe to the HIPAA Program listserv

HIPAA in the News
Enforcement Activities
Office for Civil Rights YouTube Channel

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 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 O: Data Request Agreement Request (PDF)
Form P: De-Identification of PHI (PDF)
Form Q: Is it PHI? (PDF)

HIPAA Forms | Research Gateway

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