Patient Related Forms

Medical Center Notice of Privacy Practices (NOPP)

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.

• Notice of Privacy Practices (NOPP)
• Acknowledgement of Receipt of NOPP

Campus Notice of Privacy Practices (NOPP)

Campus departments that provide care to patients need to develop their own Notice of Privacy Practices. Please contact the privacy office for guidance prior to implementing an NOPP that you have developed. Campus departments that already have NOPP 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 NOPP and to provide this documentation to the Privacy Office upon request.

Request of Accounting of Disclosure

For patients to use when requesting disclosure information:

• Informational Brochure on Accounting of Disclosure
• Request for Accounting of Disclosure Form

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 go to http://psychintra.ucsf.edu/lpphc/forms/index.asp or 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.