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Louisiana Department of Health & Hospitals | Kathy Kliebert, Secretary

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HIPAA Policies & Forms

The following is a compiled list of HIPAA Policies and Forms that are to be used by DHH employees. For more information and frequently asked questions regarding HIPAA, click here.

 

POLICIES
17.1 General Privacy Policy
18.1 Client Privacy Rights
19.1 Uses and Disclosure of Information
20.1 De-Identification of Information
21.1 Research Requests and Needs
22.1 Minimum Necessary Information
23.1 DHH Business Associates
24.1 Administrative, Technical and Physical Safeguards
25.1 Enforcement, Sanctions and Penalties

 

FORMS
Form 101P Notice of Privacy Practices
Form 102P Acknowledgement of Receipt of NPP
Form 201P Access to Records Request Form
Form 202P 30-Day Extension to Respond to Access Request
Form 203P Acceptance of Access to Records Request
Form 204P Denial of Access to Records
Form 205P Statement of Disagreement for Denial of Access to Health Information
Form 206P Response to Statement of Disagreement to Access Records
Form 207P Request for Review by the Program Privacy Officer for Denial of Access to Health Information
Form 301P Amendment/Correction of Health Record Request Form
Form 302P 30-Day Extension to Respond to Amendment Request
Form 303P Acceptance of Amendment/Correction Request
Form 304P Denial of Amendment/Correction Request
Form 305P Statement of Disagreement for Denial of Amendment or Correction of Health Information
Form 306P Response to Statement of Disagreement to Amend/Correct Health Information
Form 401P Authorization to Release or Obtain Health Information for Eligibility in Program Enrollment
Form 402P Authorization to Release or Obtain Health Information
Form 403P Revocation of Authorization
Form 404P Authorization to Release or Obtain Health Information (Statewide)
Form 501P Restriction of Use and Disclosure Request Form
Form 502P 30-Day Extension to Respond to Restriction Request
Form 503P Acceptance of Restriction Request
Form 504P Denial of Restriction Request
Form 505P Statement of Disagreement for Denial of Restriction Request
Form 506P Response to Statement of Disagreement to Restriction Request
Form 601P Privacy Complaint Report Form
Form 701P Accounting of Disclosures Request Form
Form 702P Accounting of Disclosures Tracking Form
Form 801P Privacy Statement of Understanding
  Business Associates Addendum
 

Business Associates Addendum to Purchasing Contracts or Purchase Orders