HIPAA Forms

HIPAA is the acronym for the Health Insurance Portability and Accountability Act which is intended to protect the privacy of client health information. HIPAA established standards, procedures and guidelines for how covered entities are to maintain the privacy and security of protected health information (PHI).

The Department of Social Services complies with HIPAA. To help fulfill the requirements and consistently implement HIPAA, DSS has created several forms to use help when dealing with the use or disclosure of PHI. Both staff and clients are encouraged to use these forms to help assure HIPAA requirements are met.

HIPAA forms are all in PDF
Form Number in English en Español
MO886-4061 Notice of Privacy Practices Regarding your Protected Health Information Aviso Sobre Prácticas de Privacidad en Cuanto a la Información Protegida Sorbre su Salud
MO886-4207 Authorization for Release of Medical/Health Information Autorización Para Liberar Información Médica/de Salud
MO866-4450 Request for Restriction of Health Information
MO866-4451 Individual's Request for Access to Protected Health Information Solicitud Individual Para acceso a Información de Salud Protegida
MO866-4453 Request for an Accounting of Protected Health Information Disclosures Solicitud de Informe de Divulgaciones de Información de Salud Protegida
MO866-4457 Request for Amendment/Correction of Protected Health Information