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| Form Title: | HIPAA Request for Special Privacy Protections 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 we restrict our uses and disclosures of your protected health information with respect to treatment, payment and health care operations. You also have a right to request that we restrict our uses and disclosures of your health information with respect to disclosures to members of your family and other relatives or close personal friends or other person you identify who are involved in your care or payment for your care, or to notify or assist in notifying those individuals of your location, general condition or death. UCAR does not have to agree to your request, but if we do, we will abide by our agreement until either of us terminates the agreement. |
| Who Should Use the Form: | Employee and Contact Person |
| Instructions: | The employee completes the Request for Special Privacy Protections Form, 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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