Forms and References



Please feel free to download the following forms to help you protect your health privacy.

  • Consent Form: to give all providers, including health professionals, hospitals, labs, and pharmacies.  Ask them not to disclose your health data without your consent.  You have a right to request restrictions on data disclosures; however, providers CAN refuse and disclose your records for treatment, payment, and healthcare operations use.
    •  State and federal laws give greater protections to ‘sensitive’ health information. Use this form to request that sensitive data including psychotherapy notes, mental health records, genetic information, and information about sexually-transmitted diseases not be disclosed without your consent.
  • Opt out of the AMA Database: to give all all Physicians . They may not know the AMA sells their ‘Masterfile Record’’ to marketers.
  • Request Your Records
    Section 164.524 of HIPAA: Access of Individuals to Protected Health Information
  • Complaint Form to HHS
  • Private Pay Form: if you pay for treatment or prescriptions yourself, you have a right to prevent that information from being disclosed to your health plan. Use this form to make sure that providers, health professionals, hospitals, pharmacies, and labs don’t disclose that data to your health plan.

Referral Websites


Helpful Links


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