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Form Details...
| Form Title: | HIPAA Confidential Communication Request Form |
| Last Revised: | 4/2003 |
| Purpose: | As required by the Health Information Portability and Accountability Act of 1996 (HIPAA) you have a right to request that communications concerning your personal health information be made through confidential channels. UCAR will not ask you why you are making your request, and will try to accommodate all reasonable requests. |
| Who Should Use the Form: | Employee and Contact Person |
| Instructions: | The employee completes the Confidential Communication Request Form (first tab), signs and submits to Laurie Carr (confidential internal mail to CG4 or fax 303-497-8701). |
| View the Form: | View a Blank Tab 1 Form in .pdf Format | Blank Tab 2 | Blank Tab 3 |
| Form Download Information | |
| File Format: | Excel 5.0 (.xls) |
| Download File: | Click Here to Download the Form! |
| Problems? Contact: | Laurie Carr, x8702 |
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webmaster@fanda.ucar.edu
Thank you!