Notice of privacy practice forms
- Authorization Form — Protected Health Information (PDF)
- Download and complete this form to approve the release of your protected health information to a person or entity of your choice.
- Authorization Form — Psychotherapy Notes (PDF)
- Download and complete this form to approve the release of your psychotherapy notes to a person or entity of your choice.
- Authorization Revocation Form (PDF)
- Download and complete this form to revoke your prior authorization release.
- Access Form (PDF)
- Download and complete this form to request access to specific information that we maintain about you.
- Amendment Form (PDF)
- Download and complete this form to request an amendment of the information we maintain about you.
- Restriction Request Form (PDF)
- Download and complete this form to request restrictions on the way in which we use or disclose your health information.
- Confidential Communications Form (PDF)
- Download and complete this form to request that we use an alternative address or communication mechanism.
- Confidential Communications Revocation Form (PDF)
- Download and complete this form to revoke your prior request for confidential communications.
- Accounting of Disclosures Form (PDF)
- Download and complete this form to request a listing of the specific disclosures that we have made to others of your health information.
- Privacy Complaint Form (PDF)
- Download and complete this document if you wish to make a complaint about our privacy practices or our compliance with our Notice of Privacy Practices. Alternatively, you can call our Privacy Complaint Line at 1-800-552-8278 or file your complaint directly with the Office for Civil Rights at the following address:
Office for Civil Rights
U.S. Department of Health & Human Services
233 N. Michigan Ave., Ste. 240
Chicago, IL 60601
312-886-2359
312-353-5693 (TTY)
312-886-1807 (Fax)
page modified 11/28/2011