Agreements

• Agreement - Accounting of Disclosures ( PDF, 34KB )
• Agreement - Business Associate Agreement (03/10/2011) ( PDF, 0.11MB )
• Agreement - Contract Review Form for County Covered Entity Contracts ( PDF, 34KB )
• Agreement - Detailed Data Sharing and Use Agreement ( PDF, 52KB )
• Agreement - Electronic Data Interchange Memorandum of Understanding (MOU) ( PDF, 41KB )
• Agreement - Disability Determination, Medical Examination Agreement ( PDF, 17KB )
• Agreement - HIPAA Memorandum of Understanding Short Form ( PDF, 72KB )

Notice of Privacy Practice

• Hillsborough County Notice of Privacy Practices ( PDF, 36KB )
• Notificación sobre las Normas de Privacidad en el Condado de Hillsborough ( PDF, 52KB )
• Hillsborough County Notice of Privacy Practices - Acknowledgement of Receipt ( PDF, 75KB )
• Aviso de Condado de Hillsborough de Practicas de Intimidad - Acuse de recibo

Confidentiality Agreements

• Confidentiality Agreement ( PDF, 23KB )
• Confidentiality Agreement - Aging Services ( PDF, 25KB )
• Confidentiality Agreement - HIPAA Office ( PDF, 25KB )
• Confidentiality Agreement - ITS ( PDF, 24KB )
• Confidentiality Agreement - Purchasing ( PDF, 24KB )
• Confidentiality Agreement - Volunteer Workforce ( PDF, 24KB )
• Confidentiality Agreement & Training - Volunteer Workforce ( PDF, 37KB )

Request for Access & Authorizations

• Access Request - Victims of Abuse, Neglect, or Domestic Violence ( PDF, 42KB )
• Access Request - Cadaveric Organ, Eye, or Tissue Donation ( PDF, 33KB )
• Access Request - Dying or Deceased Individuals ( PDF, 36KB )
• Access Request - Individual ( PDF, 37KB )
• Access Request - Judicial or Legal ( PDF, 48KB )
• Access Request - Law Enforcement ( PDF, 51KB )
• Access Request - Oversight or Regulatory ( PDF, 42KB )
• Access Request - Public Health Activities ( PDF, 46KB )
• Access Request - Required by Law ( PDF, 33KB )
• Access Request - Research ( PDF, 38KB )
• Access Request - Avert Serious Threat to Health or Safety ( PDF, 38KB )
• Access Request - Specialized Government Functions ( PDF, 47KB )
• Access Request - Third Party ( PDF, 36KB )
• Access Request - Workers� Compensation ( PDF, 33KB )
• Assignment - Personal Representative ( PDF, 28KB )
  
• Authorization - Instructions for Use or Disclosure ( PDF, 25KB )
  
• Authorization - Receive ( PDF, 28KB )
  
• Authorization - Release ( PDF, 39KB )
  

Disclosures

• Disclosure - Abuse, Neglect, Domestic Violence ( PDF, 36KB )
• Disclosure Notice - Abuse, Neglect, Domestic Violence ( PDF, 25KB )
• Disclosure Authorization ( PDF, 29KB )
• Disclosure Notice - Third Party ( PDF, 32KB )
• Disclosure - Privacy Action Recording Form ( PDF, 37KB )
• Disclosures Request - Individual ( PDF, 44KB )

Responses

• Response to Request - Accounting of Disclosures ( PDF, 52KB )
• Response to Request - Amend ( PDF, 35KB )
• Response to Request - Confidential Communications ( PDF, 24KB )
• Response to Request - Restrict ( PDF, 35KB )

Extensions

• Extension - Request for Access ( PDF, 24KB )
• Extension - Request for Accounting of Disclosures ( PDF, 24KB )
• Extension - Request to Amend PHI ( PDF, 23KB )
• Extension - Request for Confidential Communications ( PDF, 24KB )
• Extension - Request to Restrict PHI ( PDF, 24KB )

Revocations

• Revocation - Authorization for Release ( PDF, 23KB )
• Revocation - Personal Representative ( PDF, 27KB )

Miscellaneous

• Amend PHI Request ( PDF, 68KB )
• Breach Tool Kit ( PDF, 59KB )
• Business Associate Compliance Requirements ( PDF, 238KB )
• Complaint - Filing or Reporting ( PDF, 32KB )
• Confidential Communications Request ( PDF, 66KB )
• Fax Cover Sheet ( PDF, 30KB )
• Restrict PHI Request ( PDF, 36KB )