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Form Details...
| Form Title: | HIPAA Request for Access 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 the opportunity to inspect and copy health information that pertains to you. We will evaluate your request and will either grant it or explain the reason why the request will not be granted. Your right to access does not extend to information compiled in reasonable participation of, or for use in, a civil, criminal or administrative action or proceeding, or to information we received in confidence from someone other than another health care provider. |
| Who Should Use the Form: | Employee |
| Instructions: | The employee completes the Request Access 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!