GU Forms

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

  • FORM-04: Georgetown University Notice of Privacy Practices
  • FORM-05.A: 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

Georgetown University HIPAA Manual

  • Document containing all HIPAA forms and privacy policies

Code of Ethical Conduct

Georgetown University Compliance Helpline

Jack the Bulldog in a Georgetown striped shirt
The Georgetown University Compliance Helpline is a safe, and anonymous if desired, way to report problems or raise questions or concerns. To access the Helpline, click on Jack or call 888-239-9181