GU Forms

(Note: All forms on this page are in PDF format and require Adobe Acrobat Reader)

Form Description
FORM-04 Georgetown University Notice of Privacy Practices
FORM-05.A Individual's Request for Protected Health Information
FORM-05.B Denial of Individual's Request for Protected Health Information
FORM-06.A Request for Accounting of Disclosures
FORM-06.B Accounting for Disclosures Form
FORM-07 Request for Alternative Means of Communication
FORM-08.A Request for Amendment of Protected Health Information
FORM-08.B Amendment Acceptance-Notification Form
FORM-09 Request for Restrictions on Use and Disclosure of Protected Health Information
FORM-10 Privacy Official-Contact Information
FORM-11 Health Information Privacy Complaint Form
FORM-18 Fax Cover Sheet
FORM-21 Sample Employee Role Based Access Worksheet
FORM-23 Sample Authorization Form
BA CHART Business Associate (BA) Decision Chart
FORM 27-A Business Associate Addendum
FORM-29 Authorization for Disclosure for Philanthropy