General Forms and Procedures

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

  • 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 - Form (doc)

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

  • Health and Mental Health Disclosures and Tracking (pdf)

  • Interview, Photograph and Audio Standard (pdf)

  • Minimum Necessary Policy (pdf)

  • Record of Disclosure (pdf) | (doc)

  • Record of Inadvertent Disclosure Procedures (pdf)
  • 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)

  • Workforce Training Policy (pdf)