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The below forms may be printed, filled out and sent to the appropriate HIPAA
Covered Department or to:
Hillsborough County HIPAA Privacy Officer
P.O. Box 1110
Tampa, FL 33601-1110
All forms have been approved on December 2006.
Date Posted: April 20, 2007
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Agreements
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Notice of Privacy Practice
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Confidentiality Agreements
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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 )
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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 )
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Responses
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Extensions
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Revocations
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Miscellaneous
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