Forms

The following forms are available for reference and use (in an appropriately modified format) by each UNC Health member or affiliate. Each affiliate may also develop and utilize its own forms.

Investigations, Sanctions, Breach Reporting and Whistleblower Protections

• UNC Health Sanctions Matrix (please contact the UNC Health Privacy Office at 984.974.1069 for further information about discipline)

Health Information, Patient Rights and Medical Records

Accounting of Disclosures

• Daily Accounting of Disclosures Log
• Request for an Accounting of Disclosures Form ENGLISH
• Request for an Accounting of Disclosures Form SPANISH

Authorization for Release of Medical Information

• Release of Information (Patient or Authorized Representative) ENGLISH
• Release of Information (Patient or Authorized Representative) SPANISH
• Release of Information (Requester other than Patient or Authorized Representative) – ENGLISH
• Release of Information (Requester other than Patient or Authorized-Representative) – SPANISH

Patient Rights

• Request for Confidential Communications Form ENGLISH
• Request for Confidential Communications Form SPANISH
• Request for Amendment of Protected Health Information (PHI) Form ENGLISH
• Request for Amendment of Protected Health Information (PHI) Form SPANISH
• Request for Restrictions for Use and Disclosure of PHI – ENGLISH
• Request for Restrictions for Use and Disclosure of PHI – SPANISH

Uses and Disclosures of PHI

• Notice of Privacy Practices
• Notice of Privacy Practices – Acknowledgement of Receipt
• Use or Disclose PHI for Education, Fundraising, or Marketing- ENGLISH
• Use or Disclose PHI for Education, Fundraising, or Marketing – SPANISH

Other

• Confidentiality Statement