Lubbock Forms
Authorization for Release of Patient Information
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General English Spanish Clinical Rehabilitation Assessment English Spanish Family Medicine English Spanish Mobile Mammography Clinic English Spanish MPIP Business Office English Spanish Ophthalmology English Spanish Pediatrics C.A.R.E. Center English Spanish Pharmaceutical and Infusion Care Center English Spanish School of Nursing Wellness Center English Spanish Speech-Language & Hearing Clinic English Spanish Student Health Services English Spanish Texas Tech Diabetes Education Center English Spanish University Family Physicians English Spanish Department of Psychiatry English
Authorization for Release of Psychotherapy Notes
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General English Spanish Family Medicine English Spanish Neuropsychiatry, Division of Psychiatry English Spanish University Family Physicians English Spanish
Other Forms
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Business Associate Agreements for Contracts Word Format Business Associate Agreements for Purchase Orders PDF Format Word Format HIPAA Security Amendment (For all agreements executed before April 21, 2005)
PDF Format Word Format
| Confidential Communication Request | English | Spanish |
| Consent to Treatment | English | Spanish |
| Complaint | English | Spanish |
| Request for Accounting | English | Spanish |
| Request to Amend PHI | English | Spanish |
| Release for Media Purposes | English | Spanish |
HIPAA, Texas Tech University Health Sciences Center
806-743-4007 Fax 806-743-1515