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The following model forms and policies are offered to assist you in complying
with the HIPAA regulations.
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Note that any form you use must be translated into languages other than English as appropriate for your community.
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Remember to accommodate difficulties in communication caused by hearing loss, blindness or other similar issue.
Sample Forms
Privacy Notices:
 OAHHS Generic Notice of Privacy Practices
AHA Model Privacy Notice
Example Hospital Privacy Notice
Consumer Notices:
Consumer Information Brochure
Hospital Authorization Forms:
Adventist Authorization Form
Kaiser Authorization Form
Legacy Authorization Form
Oregon Health & Science University Hospital
PeaceHealth Authorization Form
Salem Hospital Authorization Form
West Valley Hospital
Willamette Falls Authorization Form
Willamette Valley M.C. Authorization Form
State Authorization Forms:
State Model Authorization Form
Other Authorization Forms:
Media Authorization Form
Litigation Forms:
Affidavit in Support of Subpoena for Individually Identifiable Health Information
Subpoena Checklist
Business Associate Templates:
Long Form
Short Form
Other Forms:
Request for Amendment Form
Protected Health Information Assessment Form
Accounting For Disclosures
Law Enforcement Request for Release of Information
Law Enforcement Request for Release of Information
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Sample Policies
Patient Access/Amendment to PHI and PHI Disclosure Summary
Amendment of Protected Health Information (including amendment forms)
Business Associate Grid
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