Free HIPAA reference template · v1.0 · Applies to covered entities
Free, no signup needed. A ready-to-fill spreadsheet (.xlsx) with dropdowns and examples.
Adopting this document means committing to these HIPAA controls, the 45 CFR §164 requirements it helps satisfy, by area:
Template (spreadsheet). The intake form an individual submits to request a correction to their PHI, plus the log that tracks each request to a decision within the deadline.
The record that you handle PHI-amendment requests properly and on time: an intake form for the request and a log that tracks each one to a decision within the legal deadline.
Two tabs:
Give the individual the intake tab to complete, then open a row on the log. Respond within 60 days (one 30-day extension permitted with written notice). A denial must explain the basis and the individual's right to submit a statement of disagreement. Satisfies the right to amend at 45 CFR § 164.526.
See where your organization stands on the controls this template cites.
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