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Patient Related Forms

Medical Center Notice of Privacy Practice (NPP)

This document is for departments to provide to their patients at the point of first entry. Departments need to track annual compliance and provide to Privacy Office by June 10th each year.

Campus Notice of Privacy Practice (NPP)

Campus departments that provide care to patients need to develop their own Notice of Privacy Practice. Please contact the privacy office for guidance prior to implementing an NPP that you have developed. Campus departments that already have NPP documents include the UCSF School of Nursing's Valencia Health Clinic, LPPI and the School of Dentistry. Like the Medical Center, campus departments need to document compliance with the distribution of the NPP and to provide this documentation to the Privacy Office upon request.

Request of Accounting of Disclosure

For patients to use when requesting disclosure information:

Consents and Authorizations

  • For Media Consent Forms please contact the Public Affairs' Office at (415) 476- 2557.
  • For UCSF Langley Porter Psychiatric Institute—Authorization for Release of Confidential Information or Record Form, please contact their HIMS department at (415) 476-7330.
  • All HIPAA-related forms for the medical record can be found on the HIPAA forms page of the Health Information Management Services (HIMS) web site.
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