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Oregon Department of Human Services

Tools and resources



Awareness and Education



Forms

  • OMAP's Notice of TPO Exemptions (OMAP 3079) - Assists DHS staff in receiveing individual health-related information requested from other HIPAA-covered entities.
  • Privacy forms - Ten forms were developed as part of the HIPAA Privacy implementation process. These forms give clients a variety of ways to specify their privacy requests, and they inform clients how their private information will be protected. *Note: Forms are also available in alternate languages.  Search by using the form number listed below.

    Form Number Form Name
    DHS 2090 (PDF) DHS Notice of Privacy Practices
    DHS 2092 (PDF) DHS Notice of Privacy Practices, Acknowledgment of Receipt
    DHS 2093 (Word) Request to Access Records
    DHS 2094 (Word) Request for Amendment of Health Record
    DHS 2095 (Word) Request for Restriction of Use and Disclosures
    DHS 2096 (Word) Request for Accounting of Disclosures of Health Records
    DHS 2097 (Word) Disclosures of Protected Health Information (PHI)
    DHS 2099 (Word) Authorization for Use and Disclosure of Information
    DHS 2099i (PDF) Instructions for Completing the Authorizations for Use and Disclosure of Information
    DHS 2101 (Word) Special Handling for Confidential Communications
    DHS 2102 (Word) DHS Non-Disclosure Agreement
    DHS 3001 (Word) DHS Privacy and Security Incident Report
  • HIPAA Helpers - The Privacy Program has developed the "HIPAA Helpers" packet. The packet contains a variety of forms to help DHS employees effectively request health-related information needed by DHS when conducting business with other HIPAA covered entities. The information is designed to assist in moving business forward more easily and efficiently when performing activities of treatment, payment, or health care operations (TPO).

    *Note: Forms are also available in alternate languages.  Search by using the form number listed below.

    Form Number Form Name
    DHS 2084 (pdf) HIPAA Helpers packet (includes all forms listed individually, below)
    DHS 2085 (pdf) Request for Health Information
    DHS 2086 (pdf) Request for Insurance Information
    DHS 2087 (pdf) Treatment, Payment, Health Care Operations Exceptions
    DHS 2088 (pdf) Treatment, Payment, Health Care Operations Exceptions (expanded)
    DHS 2089 (pdf) How to Handle Phone Calls


Rules, Policies and Procedures

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Page updated: October 02, 2009

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