HIPAA Compliance Forms
Frequently Used Documents
I need to:
- Request a HIPAA waiver
- Have a subject withdraw from the study in writing
- Access a data set with no HIPAA identifiers
- Access a data set with dates, city, state or zip code, but no other HIPAA identifiers
- Access the PHI of persons who are deceased
- Access PHI in preparation of research
Basic Authorization Forms
Where do I find:
- INSTRUCTIONS TO PREPARE AN AUTHORIZATION (4/8/03)
- A stand alone HIPAA form (4/22/03)
- A Spanish HIPAA form (4/22/03)
- A Child HIPAA form (4/22/03)
- A phone HIPAA form
- A no-sign HIPAA form for survey research
Elmhurst Versions
- Icahn School of Medicine | Elmhurst Hospital Center research subject authorization (8/19/03)
- Icahn School of Medicine | Elmhurst Hospital Center research subject authorization for children (8/19/03)
- Icahn School of Medicine | Elmhurst Hospital Center Authorization to be used when a signature has been waived. To be used when authorization is gotten by telephone
Queens Hospital Center Versions
- Icahn School of Medicine | Queens Hospital Center research subject authorization (7/1/04)
- Icahn School of Medicine | Queens Hospital Center research subject authorization for children (7/1/04)
- Icahn School of Medicine | Queens Hospital Center Authorization to be used when a signature has been waived. To be used when authorization is gotten by telephone
Other HIPAA-Related Documents
- Consent language for blood/tissue banking
- Consent language for database repositories
- Business Associate Agreement.
- Notice of Privacy Practices|Mount Sinai [PDF]
- Notice of Privacy Practices|HHC [PDF]
- Icahn School of Medicine | The Jewish Home and Hospital Lifecare System (4/22/03) research subject authorization