Health Insurance Portability and Accountability Act (HIPAA) Forms

Notice of Privacy Practices
NPP - (PDF)
NPP - Spanish (PDF)

Data Use Agreement
Data Use Agreement (MS Word)
Data Use Agreement (PDF)

Business Associate Agreements
BAA Template (MS Word)
BAA Template (PDF) 
BAA Affiliation Template (MS Word)
BAA Affiliation Template (PDF)
Blood Bank Example (MS Word)
Blood Bank Example (PDF)
Software Vendor (MS Word)
Software Vendor (PDF)
Third Party Administrator (CHA Example) (MS Word)
Third Party Administrator (CHA Example) (PDF)

State Law Preemption Analysis
Kentucky Revised Statutes (MS Word)
Kentucky Revised Statutes (PDF)
Kentucky Administrative Regulations (MS Word)
Kentucky Administrative Regulations (PDF)

Survey Tools
Contract Data Collection

1. Instructions
2. Sample
3. Entry

Protected Health Information Uses/Disclosures

1. Instructions
2. Uses/Disclosures Sample
3. Uses/Disclosures Entry
4. Uses/Disclosures Data Sample
5. Uses/Disclosures Data Entry

Completed surveys and questions or issues regarding the Medical Center's response to HIPAA should be addressed to Brett Short, privacy officer, Office of Corporate Compliance, 317 Health Sciences Building, 0200, or sent via e-mail to brett.short@uky.edu.

WARNING: Some Web sites to which these materials provide links for the convenience of users are not managed by the University of Kentucky. The University does not review, control, or take responsibility for the contents of those

To make an appointment or find a physician, please call UK HealthCare at 859-257-1000 or toll free 1-800-333-8874.
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Page last updated Thursday, November 12, 2009 10:06 AM