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BDC HIPPA Forms & Instructions


 

Please visit the UCD HIPPA site for more detailed information and explanations about UCD HIPPA policies on privacy and security.
*.pdf documents require Acrobat Reader. Please download here.

  1. Notice of Privacy Practices
    Patient is required to read the Notice of Privacy Practices:
    English: NPP.PDF
    Spanish: NPP.PDF
    Patient is required to sign the following acknowledgment that they received a copy of the Notice of Privacy Practices:
    English: NPP Acknowlegment.PDF
    Spanish: NPP Acknowlegment.PDF
  2. BDC Admission Form
    BDC Adminssion
  3. BDC Authorization Research Form
    BDC Authorization
  4. Shadowing Instructions and Related Forms
    BDC Shadow Instruxns
    Confidentiality Statement
    Shadow Authoriz
    Shadow Doc Script
    Shadow Staff Script
  5. PHI Release Instructions and Related Forms
    PHI Instruxns
    PHI Tracking
    PHI Request
    PHI Permission
  6. Social Security Administration Instructions and Sample Form
    PHI Instruxns
    SSA Release.PDF
  7. Pre-Reserach Form
  8. Instructions for Obtaining Patient Consent Form to Photograph/Videotape/File/Interview Patients
    Go to this website:
    http://www.kinkosdesign.net/customers/uch/archive/index.php
    At the bottom of the page, search for this Item Number: 12565
    The result will be item NUR12565-0606 Consent - Photography
    An ORIGINAL form must be used for EACH PATIENT. This includes photography used for the CDF, for any marketing purposes and for patient care!
    When ordering these forms, please note that in the field marked Dept. Code/Cost Center you will need to indicate that you "will pay with credit card". They will call for the credit card number when they receive your order.

For further information on BDC HIPPA Policies please contact the BDC HIPPA Policy & Security Officer at 303-724-6845