{"id":276,"date":"2017-06-13T14:00:45","date_gmt":"2017-06-13T18:00:45","guid":{"rendered":"https:\/\/www.bu.edu\/hipaa\/?page_id=276"},"modified":"2026-06-05T10:47:18","modified_gmt":"2026-06-05T14:47:18","slug":"forms-for-health-care-providers","status":"publish","type":"page","link":"https:\/\/www.bu.edu\/hipaa\/forms-for-health-care-providers\/","title":{"rendered":"Forms"},"content":{"rendered":"<h3>For All BU HIPAA Components<\/h3>\n<ul>\n<li><a href=\"\/hipaa\/files\/2018\/04\/HIPAA_Exceptions-Application_0118.pdf\">Application for Exception to BU HIPAA Policies<\/a><\/li>\n<li><a href=\"\/hipaa\/files\/2025\/01\/General-BU-Attestation-for-Reproductive-Health-Care-PHI.pdf\">Attestation for Reproductive Health Care PHI<\/a><\/li>\n<li><a href=\"\/hipaa\/files\/2024\/02\/HIPAA-ATTESTATION-UPON-DEPARTURE-FORM85.docx\">HIPAA Attestation Upon Departure from Boston University<\/a><\/li>\n<\/ul>\n<h3>For BU Health Care Providers<\/h3>\n<div class=\"bu_collapsible_container \" aria-live=\"polite\" data-customize-animation=\"false\"><h4 class=\"bu_collapsible\" aria-expanded=\"false\"tabindex=\"0\" role=\"button\">All Providers<\/h4><div class=\"bu_collapsible_section\" style=\"display: none;\"><\/p>\n<ul>\n<li><a href=\"\/hipaa\/files\/2024\/07\/Authorization-to-Use-and-Share-Health-Information-for-BU-Promotional-Purposes-1_Edited_6.28.24.pdf\">Authorization to Use PHI for Promotional Purposes<\/a><\/li>\n<li><a href=\"https:\/\/www.bu.edu\/hipaa\/files\/2026\/03\/Notice-of-Privacy-Practices-for-All-BU-Healthcare-Provider-HIPAA-Covered-Components.pdf\">Notice of Privacy Practices<\/a><\/li>\n<li><a href=\"https:\/\/www.bu.edu\/hipaa\/files\/2026\/02\/Acknowledgement-that-Notice-of-Privacy-Practices-was-given.pdf\">Acknowledgement That Notice of Privacy Practices Was Given<\/a><\/li>\n<\/ul>\n<p><\/div>\n<\/div>\n\n<p>&nbsp;<\/p>\n<div class=\"bu_collapsible_container \" aria-live=\"polite\" data-customize-animation=\"false\"><h4 class=\"bu_collapsible\" aria-expanded=\"false\"tabindex=\"0\" role=\"button\">Danielsen Institute<\/h4><div class=\"bu_collapsible_section\" style=\"display: none;\"><\/p>\n<ul>\n<li><a href=\"\/hipaa\/files\/2025\/01\/Danielson-Institute-HIPAA-Attestation-for-Reproductive-Health-PHI.pdf\">Attestation for Reproductive Health PHI<\/a><\/li>\n<li><a href=\"\/hipaa\/files\/2025\/08\/DI-Authorization-to-Disclose-PHI.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">Authorization for Release of PHI (General Purpose Auth)<\/a><\/li>\n<li><a href=\"\/hipaa\/files\/2017\/04\/2-Danielsen-Authorization-to-Disclose-Health-Info-for-Educational-Purposes.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">Authorization to Disclose Health Info for Educational Purposes<\/a><\/li>\n<li><a href=\"\/hipaa\/files\/2017\/04\/3-Danielsen-Authorization-to-Use-and-Disclose-Health-Information-In-a-Professional-Publication.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">Authorization to Use and Disclose PHI in a Professional Publication <\/a><\/li>\n<li><a href=\"\/hipaa\/files\/2017\/04\/4-Authorization-for-Other-Providers-to-send-Records-to-DI.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">Authorization for Other Providers to send Records to DI<\/a><\/li>\n<li><a href=\"\/hipaa\/files\/2017\/04\/8-Danielsen-Institute-Request-for-an-Accounting.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">Request for an Accounting <\/a><\/li>\n<li><a href=\"\/hipaa\/files\/2017\/04\/9-Danielsen-Institute-Request-for-a-Restriction-on-Disclosure-of-Protected-Health-Information-PHI.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">Request for a Restriction <\/a><\/li>\n<li><a href=\"\/hipaa\/files\/2017\/04\/10-Danielsen-Institute-Request-for-Amendment-of-Protected-Health-Information.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">Request for Amendment of PHI <\/a><\/li>\n<li><a href=\"\/hipaa\/files\/2017\/04\/11-Danielsen-Institute-Request-for-Confidential-or-Alternate-Mode-of-Communications.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">Request for Confidential or Alternate Mode of Communication <\/a><\/li>\n<\/ul>\n<p><\/div>\n<\/div>\n\n<p>&nbsp;<\/p>\n<div class=\"bu_collapsible_container \" aria-live=\"polite\" data-customize-animation=\"false\"><h4 class=\"bu_collapsible\" aria-expanded=\"false\"tabindex=\"0\" role=\"button\">GSDM Dental Health Centers<\/h4><div class=\"bu_collapsible_section\" style=\"display: none;\"><\/p>\n<h5>English<\/h5>\n<ul>\n<li><a href=\"\/hipaa\/files\/2025\/01\/GSDM-Dentral-Treatment-Center-HIPAA-Attestation-for-Reproductive-Health-PHI.pdf\">Attestation for Reproductive Health PHI<\/a><\/li>\n<li><a href=\"\/hipaa\/files\/2023\/08\/Dental-Educ-Acad-Authorization-6.26.19.pdf\">Authorization for Educational and Academic Purposes<\/a><\/li>\n<li><a href=\"\/hipaa\/files\/2019\/06\/Dental-Publication-Authorization-6.26.19.pdf\">Authorization to Use Dental Info in Publication<\/a><\/li>\n<li><a href=\"\/hipaa\/files\/2019\/07\/Authorization-for-Other-Provider-Records-to-be-Sent-to-GSDM-7.18.19.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">Authorization for Other Provider Records to be Sent to GSDM<\/a><\/li>\n<li><a href=\"https:\/\/www.bu.edu\/dental\/patient-care\/dental-records\/\">Authorization to Release Dental Records<\/a><\/li>\n<li><a href=\"\/hipaa\/files\/2017\/04\/8-Dental-Request-for-an-Accounting.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">Request for an Accounting<\/a><\/li>\n<li><a href=\"\/hipaa\/files\/2017\/04\/9-Dental-Request-for-a-Restriction-on-Disclosure-of-Protected-Health-Information-PHI.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">Request for a Restriction<\/a><\/li>\n<li><a href=\"\/hipaa\/files\/2017\/04\/10-Dental-Request-for-Amendment-of-Protected-Health-Information.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">Request for Amendment<\/a><\/li>\n<li><a href=\"\/hipaa\/files\/2017\/04\/11-Dental-Request-for-Confidential-or-Alternate-Mode-of-Communications.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">Request for Confidential or Alternate Mode of Communication<\/a><\/li>\n<li><a href=\"\/hipaa\/files\/2023\/07\/Prep-to-Research-Request-Form-2023_07_21-1.pdf\">Prep to Research Request Form<\/a><a href=\"\/hipaa\/files\/2017\/06\/GSDM-PTC-Workstation-and-Device-Use-Procedure.docx\"><\/a><\/li>\n<\/ul>\n<h5>Spanish<\/h5>\n<ul>\n<li><a href=\"\/hipaa\/files\/2020\/02\/Sp-Dental-Educ-Acad-Authorization.pdf\">Authorization for Educational and Academic Purposes<\/a><\/li>\n<li><a href=\"\/hipaa\/files\/2020\/02\/Sp-Dental-Publication-Authorization.pdf\">Authorization to Use Dental Info in Publication<\/a><\/li>\n<li><a href=\"\/hipaa\/files\/2020\/02\/Sp-4-Authorization-for-Other-Provider-Records-to-be-Sent-to-GSDM.pdf\">Authorization for Other Provider Records to be Sent to GSDM<\/a><\/li>\n<li><a href=\"https:\/\/www.bu.edu\/dental\/patient-care\/dental-records\/\">Authorization to Release Dental Records<\/a><\/li>\n<li><a href=\"\/hipaa\/files\/2020\/02\/Sp-8-Dental-Request-for-an-Accounting.pdf\">Request for an Accounting<\/a><\/li>\n<li><a href=\"\/hipaa\/files\/2020\/02\/Sp-9-Dental-Request-for-a-Restriction-on-Disclosure-of-Protected-Health-Information-PHI.pdf\">Request for a Restriction<\/a><\/li>\n<li><a href=\"\/hipaa\/files\/2020\/02\/Sp-10-Dental-Request-for-Amendment-of-Protected-Health-Information.pdf\">Request for an Amendment<\/a><\/li>\n<li><a href=\"\/hipaa\/files\/2020\/02\/Sp-11-Dental-Request-for-Confidential-or-Alternate-Mode-of-Communications.pdf\">Request for Confidential or Alternate Mode of Communication<\/a><\/li>\n<\/ul>\n<p><\/div>\n<\/div>\n\n<p>&nbsp;<\/p>\n<div class=\"bu_collapsible_container \" aria-live=\"polite\" data-customize-animation=\"false\"><h4 class=\"bu_collapsible\" aria-expanded=\"false\"tabindex=\"0\" role=\"button\">Sargent Choice Nutrition<\/h4><div class=\"bu_collapsible_section\" style=\"display: none;\"><\/p>\n<ul>\n<li><a href=\"\/hipaa\/files\/2025\/01\/Sargent-Choice-Nutrition-Center-Attestation-for-Reproductive-Health-PHI.pdf\">Attestation for Reproductive Health PHI<\/a><\/li>\n<li><a href=\"\/hipaa\/files\/2017\/04\/1-Sargent-Choice-Authorization-for-Release-for-PHI.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">Authorization for Release (General Purpose Auth)<\/a><\/li>\n<li><a href=\"\/hipaa\/files\/2017\/04\/2-Sargent-Authorization-to-Disclose-Health-Info-for-Educational-Purposes.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">Authorization to Disclose PHI for Educational Purposes<\/a><\/li>\n<li><a href=\"\/hipaa\/files\/2017\/04\/3-Sargent-Authorization-to-Use-and-Disclose-Health-Information-In-a-Professional-Publication.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">Authorization to Use and Disclose PHI In a Professional Publication<\/a><\/li>\n<li><a href=\"\/hipaa\/files\/2017\/04\/4-Authorization-for-Other-Providers-to-send-Records-to-Sargent-Choice.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">Authorization for Other Providers to send Records to Sargent Choice<\/a><\/li>\n<li><a href=\"\/hipaa\/files\/2017\/04\/8-Sargent-Choice-Request-for-an-Accounting.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">Request for an Accounting<\/a><\/li>\n<li><a href=\"\/hipaa\/files\/2017\/04\/9-Sargent-Choice-for-a-Restriction-on-Disclosure-of-Protected-Health-Information-PHI.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">Request for a Restriction<\/a><\/li>\n<li><a href=\"\/hipaa\/files\/2017\/04\/10-Sargent-Choice-for-Amendment-of-Protected-Health-Information.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">Request for Amendment<\/a><\/li>\n<li><a href=\"\/hipaa\/files\/2017\/04\/11-Sargent-Request-for-Confidential-or-Alternate-Mode-of-Communications.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">Request for Confidential or Alternate Mode of Communication<\/a><\/li>\n<\/ul>\n<p><\/div>\n<\/div>\n\n<p>&nbsp;<\/p>\n<div class=\"bu_collapsible_container \" aria-live=\"polite\" data-customize-animation=\"false\"><h4 class=\"bu_collapsible\" aria-expanded=\"false\"tabindex=\"0\" role=\"button\">BU Rehabilitation<\/h4><div class=\"bu_collapsible_section\" style=\"display: none;\"><\/p>\n<ul>\n<li><a href=\"\/hipaa\/files\/2025\/01\/BU-Rehabilitation-Services-Attestation-for-Reproductive-Health-PHI-1.pdf\">Attestation for Reproductive Health PHI<\/a><\/li>\n<li><a href=\"\/hipaa\/files\/2017\/06\/Rehab-General-Authorization-for-Release-for-PHI-6-16-2017.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">BU Rehab General Authorization<\/a><\/li>\n<li><a href=\"\/hipaa\/files\/2018\/02\/BU-Rehab-Auth-for-Educational-Purposes-2-1-2018.pdf\">BU Rehab Authorization for Educational Purposes<\/a><\/li>\n<li><a href=\"\/hipaa\/files\/2017\/04\/3-Rehab-Authorization-to-Use-and-Disclose-Health-Information-In-a-Professional-Publication.pdf\" target=\"_blank\" rel=\"noopener noreferrer\"> Authorization to Use PHI in a Professional Publication<\/a><\/li>\n<li><a href=\"\/hipaa\/files\/2017\/04\/4-Authorization-for-Other-Providers-to-send-Records-to-BU-Rehab.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">Authorization for Other Providers to send Records to BU Rehab<\/a><\/li>\n<li><a href=\"\/hipaa\/files\/2017\/04\/8-Rehab-Services-Request-for-an-Accounting.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">Request for an Accounting<\/a><\/li>\n<li><a href=\"\/hipaa\/files\/2017\/04\/9-Rehab-Services-for-a-Restriction-on-Disclosure-of-Protected-Health-Information-PHI.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">Request for a Restriction<\/a><\/li>\n<li><a href=\"\/hipaa\/files\/2017\/04\/10-Rehab-Services-Request-for-Amendment-of-Protected-Health-Information.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">Request for Amendment<\/a><\/li>\n<li><a href=\"\/hipaa\/files\/2017\/04\/11-Rehab-Services-Request-for-Confidential-or-Alternate-Mode-of-Communications.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">Request for Confidential or Alternate Mode of Communication<\/a><\/li>\n<\/ul>\n<p><\/div>\n<\/div>\n\n<p>&nbsp;<\/p>\n<h3>For BU Researchers<a href=\"\/hipaa\/files\/2021\/09\/Patient-or-Subject-Request-For-Non-Secure-Communication-example-form.docx\"><\/a><\/h3>\n<ul>\n<li><a href=\"\/hipaa\/files\/2023\/05\/Authorization-to-Use-or-Disclose-Health-Information.pdf\"><span>Authorization to Disclose Health Information for Research<\/span><\/a><a href=\"\/hipaa\/files\/2024\/02\/HIPAA-ATTESTATION-UPON-DEPARTURE-FORM85.docx\"><\/a><\/li>\n<li><a href=\"\/hipaa\/files\/2026\/02\/Prep-to-Research-Request-Form.pdf\">Prep to Research Request Form<\/a><\/li>\n<\/ul>\n","protected":false},"excerpt":{"rendered":"<p>For All BU HIPAA Components Application for Exception to BU HIPAA Policies Attestation for Reproductive Health Care PHI HIPAA Attestation Upon Departure from Boston University For BU Health Care Providers &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; For BU Researchers Authorization to Disclose Health Information for Research Prep to Research Request Form<\/p>\n","protected":false},"author":12824,"featured_media":0,"parent":0,"menu_order":2,"comment_status":"closed","ping_status":"closed","template":"","meta":[],"_links":{"self":[{"href":"https:\/\/www.bu.edu\/hipaa\/wp-json\/wp\/v2\/pages\/276"}],"collection":[{"href":"https:\/\/www.bu.edu\/hipaa\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.bu.edu\/hipaa\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.bu.edu\/hipaa\/wp-json\/wp\/v2\/users\/12824"}],"replies":[{"embeddable":true,"href":"https:\/\/www.bu.edu\/hipaa\/wp-json\/wp\/v2\/comments?post=276"}],"version-history":[{"count":51,"href":"https:\/\/www.bu.edu\/hipaa\/wp-json\/wp\/v2\/pages\/276\/revisions"}],"predecessor-version":[{"id":881,"href":"https:\/\/www.bu.edu\/hipaa\/wp-json\/wp\/v2\/pages\/276\/revisions\/881"}],"wp:attachment":[{"href":"https:\/\/www.bu.edu\/hipaa\/wp-json\/wp\/v2\/media?parent=276"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}