Privacy Forms

For more information send us an email or phone 619-338-2808.

Click on the link below to download the file you need.

Privacy Incident Reporting Form – This form is to be used by County and Contractor staff to report suspected and actual privacy incidents to the HHSA Privacy Officer.

Protected Health Information Privacy Complaint Filing Form - The HIPAA Privacy Rule allows you to make a complaint regarding violation of your privacy rights by a covered entity. If you believe that a person, agency or program covered under HIPAA violated your or someone else's health information privacy rights, or committed another violation of the Privacy Rule, you may file a complaint with the County of San Diego Privacy Officer.

Authorization to Use or Disclose Protected Health Information (PHI) - This authorization form may be used by you as a patient/client of the County in order to initiate a request to have PHI about you disclosed outside of the Health and Human Services Agency or between Programs with sensitive confidentiality requirements.

Revocation of Authorization to Use or Disclose Protected Health Information - This form is now required under HIPAA. If you want to revoke an authorization, it must be done in writing and will be processed through the appropriate Health and Human Services Agency health records office.

Request for Accounting of Disclosures of Protected Health Information - This form is now required under HIPAA. If you want to request an accounting you must do so in writing and it will be processed through the appropriate Health and Human Services Agency health records office.

Request for Restrictions on Uses and Disclosures of Protected Health Information (PHI)- This form allows you to request restriction on the uses and disclosures of your PHI for treatment, payment and health care operations.

 

For more information send us an email or phone 619-338-2808.