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Purdue University -

Procedures and Forms - General

Access to Health and Mental Health Records by the Individual or their Legal Representative (pdf)

Authorization for Use, Disclosure or Release of PHI and Medical Records Form (doc)

Request to Revoke Authorization - Form (pdf) (doc)

Revocation Verification Letter Template (doc)

Breach Notification Policy (pdf)
Breach Notification Procedures (pdf)

Confidentiality Agreement - Form (pdf)
Confidentiality Agreement – Purdue Clinical Training Programs - Form (doc)
Confidentiality Agreement - Student Affiliation-Work External to Purdue - Form (pdf)
Confidentiality Agreement – Contractors - Form (pdf)

Confidential Destruction Certificate (pdf)  (doc)

Designation of Individuals Who are Involved in My Payment or Treatment Decisions - Form (doc)

Distribution of the Notice of Privacy Practices - Procedure (pdf)
Distribution of the Notice of Privacy Practices - Letter (doc)

Interview, Photograph and Audio Standard (pdf)

Minimum Necessary Policy (pdf)

Record of Disclosure (pdf)    (doc)

Record of Inadvertent Disclosure of PHI - Form (pdf)     (doc)
       Inadvertent Disclosure Confidentiality Agreement (pdf) (doc)
       Inadvertent Disclosure Disposal Verification (pdf) (doc)

Request of Amendment of PHI - Procedure (pdf)
Request of Amendment of PHI from an Individual - Form (pdf)     (doc)
Request of Amendment of PHI from an Entity - Form (pdf)     (doc)

Request of Confidential Communications (pdf)

Request for the Restriction of the Use or Disclosure of PHI - Policy and Procedure (pdf)
Request for the Restriction of the Use or Disclosure of PHI-Form (pdf)     (doc)

Tracking and Releasing Policy (pdf)

Workforce Training Policy (pdf)

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please contact HIPAA Security Officer at hipaa-privacy@purdue.edu

HIPAA Compliance, 601 Stadium Mall Dr, West Lafayette, IN 47907, (765) 496-1927
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