Privacy Forms

HIPAA is the acronym for the Health Insurance Portability and Accountability Act which is intended to protect the privacy of client health information. HIPAA established standards, procedures and guidelines for how covered entities are to maintain the privacy and security of protected health information (PHI).

  • Privacy Standards regulate the use and disclosure of PHI held by covered entities.
  • Security standards regulate how Electronic Protected Health Information is to be protected by establishing minimum requirements for administrative, physical and technical safeguards.
  • Enforcement Rule sets the penalties for violating HIPAA rules and establishes procedures for investigations and hearings.

The Department of Social Services complies with HIPAA. To help fulfill the requirements and consistently implement HIPAA, DSS has created several forms to use help when dealing with the use or disclosure of PHI. Both staff and clients are encouraged to use these forms to help assure HIPAA requirements are met.

HIPAA forms are all in PDF

Form Numberin Englishen Español
MO886-4061
MO866-4450Request for Restriction of Health Information 
MO866-4451Individual's Request for Access to Protected Health InformationSolicitud Individual Para acceso a Información de Salud Protegida
MO866-4453Request for an Accounting of Protected Health Information DisclosuresSolicitud de Informe de Divulgaciones de Información de Salud Protegida
MO866-4457Request for Amendment/Correction of Protected Health InformationSolicitud Para Enmienda/Corrección De La Información De Salud Protegida
MO886-4590Notice of Privacy Practices Regarding Personally Identifiable InformationAviso Sobre las Prácticas de Privacidad relacionadas con la Información de Identificación Personal (PII)
MO886-4596Authorization for Disclosure of Confidential InformationAutorización Para Divulgar InformaciÓn Confidencial