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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.
  • Safeguards Assessment - Administrative, Technical and Physical Safeguards Policy AS-100-05 requires that we take reasonable steps to safeguard confidential information. Information to be safeguarded may be in any medium including paper, electronic, oral and visual. We are required to assess those safeguards annually. Use the DHS 3000, Safeguards Assessment Tool to complete an annual assessment. The form is available in PDF or Word formats.
  • 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 2009 DHS Fax Cover Sheet - PDF,   Word or Wordperfect
    DHS 2090 (pdf) DHS Notice of Privacy Practices
    DHS 2092 (pdf) DHS Notice of Privacy Practices, Acknowledgment of Receipt
    DHS 2093 (pdf) Access to Records Request Form
    DHS 2094 (pdf) Amendment of Health Record Request Form
    DHS 2095 (pdf) Restriction of Use and Disclosures Request Form
    DHS 2096 (pdf) Accounting of Disclosures Request Form
    DHS 2097 (pdf) Disclosures of Protected Health Information
    DHS 2099 Authorization for Use and Disclosure of Information -
    Forms: PDF, Word, or Wordperfect     Instructions: PDF, Word
  • 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
 

Frequently Asked Questions

 

Rules, Policies and Procedures

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Page updated: October 25, 2007

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