HIPAA Forms

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OUR SHARED HIPAA FORMS

HIPAA is the acronym for the Health Insurance Portability and Accountability Act which is intended to protect the privacy of client health information. HIPAA established standards, procedures and guidelines for how covered entities are to maintain the privacy and security of protected health information (PHI).

  • Privacy Standards regulate the use and disclosure of PHI held by covered entities.
  • Security standards regulate how Electronic Protected Health Information is to be protected by establishing minimum requirements for administrative, physical and technical safeguards.
  • Enforcement Rule sets the penalties for violating HIPAA rules and establishes procedures for investigations and hearings.

We comply with HIPAA. To help fulfill the requirements and consistently implement HIPAA, we have created several forms to use help when dealing with the use or disclosure of PHI. Both staff and clients are encouraged to use these forms to help assure HIPAA requirements are met.

ZIP archived,

uncompressed HIPAA forms are all "form-fillable" PDF's

Form Numberin EnglishE-mail submission?
MO886-4061Notice of Privacy Practices Regarding your Protected Health InformationN/A
MO886-4207Authorization for Release of Medical/Health InformationYes
MO866-4450Request for Restriction of Health InformationYes
MO866-4451Individual's Request for Access to Protected Health InformationYes
MO866-4453Request for an Accounting of Protected Health Information DisclosuresYes
MO866-4457Request for Amendment/Correction of Protected Health InformationYes



GAMMA HEALTHCARE, INC.


MAIN OFFICE
1717 West Maud Poplar Bluff, MO 63901 
Phone: (573) 727-5600
Administration Fax: (573) 785-0753
Customer Service Fax: (573) 785-2369
Front Desk Fax: (573) 727-5686
Billing Fax: (573) 785-0125
HR Fax: (573) 727-5627
Lab/Processing Fax: (573) 727-5689

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