These are member protected HIPAA/HITECH forms. Some of the forms are both interactive and static. Interactive allows completion of the form on a computer. Users should remember to save the form under a different name when completed. Static means that the form needs to be printed, then completed. The forms are created and useable as Adobe Acrobat Forms and as such have data and image fields for completion by members.
In the upper left of most documents, members may move their cursor until the icon changes indicating an image field. If they “click” on the field it will open their files for insertion of clip art or some other image such as a logo. Use of the field is not required but it will give members the change to add some originality to the document.
Some documents like the new patient form have fields that must be completed with the correct information in order to work properly. For example, in those sections requiring a social security number, the data requirements are set to only accept the correct amount of numbers or a mistake will show an error and ask for the correct information.When using document forms that members are likely to continually reuse (e.g. the business associate agreement), members must be sure to save the document after completion under a new file name to avoid overwriting the original form.
With the notice of privacy practices, a tri-fold brochure is supplied that permits a logo and practice address on the front cover and contact information on the back. This form may be printed in duplex on a decent office printer or may be sent to a printer for bulk printing. There is also a version with text only should members wish to simply print out 8.5 x 11 sheets.
Finally, there are some “static” Adobe Acrobat documents that members may simply print and complete in writing rather than from a computer.
Click here to access the explanation on how to use these forms. Click on each highlighted area for forms access.
Summary gives detailed explanation of each form and its use.
1. New Patient Registration Form (Interactive)/New Patient Registration Form (Static).These are standard intake forms that include insurance nformation, request for communication preferences, assignment of benefits and authorization for release of information for payment and insurance benefits. Practitioners can choose to use these forms or cointinue with their existing forms.
2. Customizable Notice of Privacy Practice brochure. Included is a sample trifold for the law firm showing use of logo space (photo) and address. Here is the link to the summary of the privacy rules. These notices must be delivered to new patients.
3. Notice of Privacy Practices Acknowledgement (Interactive)/Notice of Privacy Practices Acknowledgement (Static). These acknowledgements mujst be signed by new patients.
4. Updated Authorization of Release of Health Information includes section for minors and notice of limit expiration date for release of information related to employment. Authorization is required for use and disclosure other than those already permitted by HIPAA such as disclosure for treatment, payment, and health care operations. A copy of the 2007 Washington Minor Health Care Rights prepared by King County Public Health.
5. Patient Statement of Financial Responsibility and Health Plan Coverage Form developed to create a record for practitioners of insurance verification and patient acceptance of financial responsibility. The Form includes a statement of financial responsibility for missed appointments and insurer non-coverage of these liabilities.
6. Non-Covered services Disclosure Form developed to comply with network and health plan program requirements that practitioners advise patients of lack of coverage and obtain consent for patient liability for care prior to delivery of care.
7. Blank Fax Cover Sheet with Confidentiality Form provides confidentiality notice to recipients.
8. New Practitioner Checklist used in part to verify communication and training of HIPAA requirements for new health care practitioners added to clinic staff.
9. HIPAA Security and Breach Notification compliance Checklist designed to walk the practitioner through new regulatory requirements.
10. Patient Request to Copy Records Form required to comply with HIPAA. Practitioners should use this form whenever patients request access to their own records.
11. Patient Privacy Complaint Form required to comply with HIPAA requirements that practitioners advise patients of right to complain and keep record of such complaints.
12. Patient Request for Accounting of Record Disclosures Form required to comply with HIPAA and should be used whenever a patient requests an accounting of the disclosures made by practitioner.
13. Authorization for Release of Information for marketing purposes Form should be used whenever a Practitioner is uncertain as to whether a praticular use or disclosure of information related to products and services falls outside the HIPAA exceptions for practitioners communication with patients.
14. Patient Request for Alternative Communications Form provides method of compliance with HIPAA requirements that patients be permitted to direct communications to a certain person or by a certain method.
15.General Health Care Employee Confidentiality Agreement notice is to be used whenever a Business Associate Agreement is not necessary but a promise of confidentiality is advisable.
16. Business Associate Agreement Contract includes elements of HITECH and other HIPAA rules. (Although this business associate agreement satisfies all practitioner needs, many current and potential business associates will have their own standard form that my or may not comply with current legal requirements. Furthermore, practitioners are advised to review other business associate agreements to ensure protection of practitioner from business associate negligence.)
17. Breach notification sample letters to patients and to HHS. These requirements were adopted last fall and practitioners must familiarize themselves both with the security requirements and the breach notification standards.Breach Notification Sample Letter to Patients Breach Notification Sample Letter to HHS
18. FTC Identity Theft Reporting Form is a standard form developed by the FTC for use by affected customers. Practitioners may provide this form to patients who either the Practitioner or patient believes may be affected by an actual or potential theft of indentity information.