HIPAA Policies and Related Forms

The following is a compiled list of HIPAA Policies and Forms that are to be used by LDH employees. For more information and frequently asked questions regarding HIPAA, click here.

 

POLICIES
17.1	General Privacy Policy
18.1	Client Privacy Rights
19.1	Uses and Disclosure of Information
20.1	De-Identification of Information
21.1	Research Requests and Needs
22.1	Minimum Necessary Information
23.1	LDH Business Associates
24.1	Administrative, Technical and Physical Safeguards
25.1	Enforcement, Sanctions and Penalties

 

FORMS
Form 101P	Notice of Privacy Practices
Form 102P	Acknowledgement of Receipt of NPP
Form 201P	Access to Records Request Form
Form 202P	30-Day Extension to Respond to Access Request
Form 203P	Acceptance of Access to Records Request
Form 204P	Denial of Access to Records
Form 205P	Statement of Disagreement for Denial of Access to Health Information
Form 206P	Response to Statement of Disagreement to Access Records
Form 207P	Request for Review by the Program Privacy Officer for Denial of Access to Health Information
Form 301P	Amendment/Correction of Health Record Request Form
Form 302P	30-Day Extension to Respond to Amendment Request
Form 303P	Acceptance of Amendment/Correction Request
Form 304P	Denial of Amendment/Correction Request
Form 305P	Statement of Disagreement for Denial of Amendment or Correction of Health Information
Form 306P	Response to Statement of Disagreement to Amend/Correct Health Information
Form 401P	Authorization to Release or Obtain Health Information for Eligibility in Program Enrollment
Form 402P	Authorization to Release or Obtain Health Information
Form 403P	Revocation of Authorization
Form 501P	Restriction of Use and Disclosure Request Form
Form 502P	30-Day Extension to Respond to Restriction Request
Form 503P	Acceptance of Restriction Request
Form 504P	Denial of Restriction Request
Form 505P	Statement of Disagreement for Denial of Restriction Request
Form 506P	Response to Statement of Disagreement to Restriction Request
Form 601P	Privacy Complaint Report Form
Form 701P	Accounting of Disclosures Request Form
Form 702P	Accounting of Disclosures Tracking Form
Form 801P	Privacy Statement of Understanding
	Business Associates Addendum
	Business Associates Addendum to Purchasing Contracts or Purchase Orders