BDC HIPAA Forms & Instructions*

Please visit the UCD HIPAA site for more detailed information and explanations about UCD HIPAA policies on privacy and security.

1. Notice of Privacy Practices
Patient is required to read the Notice of Privacy Practices:
NPP.pdf in English (pdf format)
NPP_es.pdf in Spanish (pdf format)
Patient is required to sign the following acknowledgment that they received a copy of the Notice of Privacy Practices:
NPP_acknowl.pdf in English (pdf format)
NPP_acknowl_es.pdf in Spanish (pdf format)

2. BDC Admission form:
BDC_admission.doc (Word document)

3. BDC Authorization form:
BDC_authoriz.doc (Word document)

4. Shadowing instructions and related forms (Word documents):
BDCshadowInstruxns.doc
Confidentiality_Statement.doc
Shadow_Authoriz.doc
Shadow_Doc_Script.doc
Shadow_Staff_Script.doc

5. PHI Release instructions and related forms:
PHI_Instruxns.doc (Word document)
PHI_Tracking.doc (Word document)
PHI_Request.doc (Word document)
PHI_Permission.doc (Word document)

6. Social Security Administration instructions and sample form:
PHI_Instruxns.doc (Word document)
SSA_Release.pdf (pdf format)

7. Pre-Research Form:
PreResearchForm.doc (Word document)

8. Instructions for obtaining patient consent form to photograph/videotape/film/interview patients:
Go to this web site:
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 NUR12565-0503 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.

*pdf documents require Acrobat Reader. Please download here.

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