Patient HIPAA Forms

The Health Insurance Portability and Accountability Act of 1996 includes a regulatory requirement to provide every new patient with the organization’s Notice of Privacy Practices (NOPP). The NOPP informs patients how their protected health information (PHI) may be accessed, used, and disclosed by Columbia University Healthcare Component (CUHC) and how to exercise their rights with respect to their PHI. The forms below can be utilized to address your patient rights.

Authorization to Disclose Medical Information

• Authorization to Disclose Medical Information (English)
• Authorization to Disclose Medical Information (Spanish)
• Authorization to Disclose Medical Information (Chinese)
  • Health Information Management Contact Information
  • Employee FAQs for Authorization to Disclose PHI
  • Patient FAQs to Obtain Outpatient Medical Records
  • Patient FAQs to Obtain Hospital Medical Records

  Notice of Privacy Practices (NOPP)

  • NOPP Brochure (English, Spanish, Chinese)
  • NOPP Paper Handout (English, Spanish, Chinese)
    • Notice of Privacy Practices FAQs

    NOPP Patient Acknowledgement Form

    • Acknowledgement Form (English)
    • Acknowledgement Form (Spanish)
    • Acknowledgement Form (Chinese)

    Privacy Rights Complaint Form

    • Submit Complaint Form by Mail
    • Submit Complaint Form Online

    Additional Patient Forms

    • NYS DOH Legal Authorization Form (can be used to request PHI from another organization)
    • Authorization for Release of Health Information to a Designated Party (English)
    • Authorization for Release of Health Information to a Designated Party (Spanish)
    • Connect Patient Portal Proxy Access (to be used to give another adult or parent of a minor between the ages of 12-18 years old access to your Connect Patient Portal account)
      • Connect Patient Portal Proxy Access Authorization Form