TTUHSC Office of Institutional Compliance
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TTUHSC Universal HIPAA Forms

Notice of Privacy Practices

Notice of Privacy Practices (NPP) English Version Spanish Version

Authorization for Release of Patient Information


Authorization Form for Release of Patient Information
Authorization Form Lubbock
Authorization Form Amarillo
Authorization Form Permian Basin     

Fax Cover Sheet

HPP 4.6 Faxing Protected Health Information

Fax Cover Sheet Lubbock                                     
Fax Cover Sheet Amarillo
Fax Cover Sheet Permian Basin

HIPAA Research Study Forms

Authorization to Use and Disclose PHI for Research Study*form included as part of TTUHSC Biomedical Informed Consent template found in IRIS

 
Addendum to Authorization to Use and/or Disclose PHI for Research Study English Version Spanish Version
Principal Investigator's Request to Use and Disclose PHI without an Authorization English Version
PDF Format
Word Format
No Spanish Version
Available at this time

Business Associate Agreement and Data Use Agreement Information

HIPAA Business Associate Agreement Business Associate Agreement Form Guideline for Use
HIPAA Data Use Agreement Data Use Agreement Form Guideline for Use

Patients' Rights Forms

Consent to Treatment (Guideline) English Version Spanish Version
Consent to Treatment "Opt Out" Form English Version Spanish Version
Patient Request for Acess of Health Information English Version Spanish Version
Request for Accounting Form English Version Spanish Version
Request to Amend PHI Form English Version Spanish Version
Confidential Communication Request English Version Spanish Version
Alternate Forms of Communication English Version Spanish Version
Privacy Complaint Form English Version Spanish Version

Photo Consent Form

Consent & Release to Use Image or Information Form
(see HSC OP 52.15)
English Version Spanish Version
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