HIPAA Privacy Forms

The Health Insurance Portability and Accountability Act (HIPPA) is legislation that provides data privacy and security provisions for safeguarding medical information. Please use the following forms when you want to give us specific instructions regarding how your personal information is used or shared with others.

All forms below are in PDF format. If you have trouble opening any of the forms, download Adobe Reader for free. 

• Do Not Contact Form: Use this form if you wish to stop receiving fundraising or marketing information.
• Patient Authorization Forms
  • For Releasing Documents: Use this form when you would like Einstein to release your information to outside parties.
  • Patient Revocation of Authorization to Disclose and Use PHI Form: Use this form if you want to revoke (take back) your authorization.
• Patient Request for Accounting Form: Use this form to receive an accounting of certain releases of your personal health information. This accounting will not include information released or used for treatment, payment or operations and it will not include any information we released with your authorization.
• Patient Request for Amendment Form:  
• Use this form to request corrections to your medical record.
• Patient Request for Restrictions Form: Use this form for requesting that Einstein restrict normal uses of your health information.