{"id":7924,"date":"2022-02-24T12:31:31","date_gmt":"2022-02-24T20:31:31","guid":{"rendered":"https:\/\/depts.washington.edu\/comply\/?page_id=7924"},"modified":"2026-04-21T09:52:29","modified_gmt":"2026-04-21T16:52:29","slug":"policy-resources","status":"publish","type":"page","link":"https:\/\/depts.washington.edu\/comply\/policy-resources\/","title":{"rendered":"Policy Guidance, Forms &#038; Templates"},"content":{"rendered":"<h2><strong>Forms<\/strong><\/h2>\n<div class=\"su-row\">\n<div class=\"su-column su-column-size-1-2\">\n<div class=\"su-column-inner su-u-clearfix su-u-trim\">\n<ul>\n<li><a href=\"https:\/\/one.uwmedicine.org\/sites\/uwm-formsrep\/FormsLibrary\/U3162.pdf\" target=\"_blank\" rel=\"noopener noreferrer\" data-kmt=\"1\">Accounting of Disclosure (UH3162) \u2013 104.F14<i class=\"fa fa-external-link\"><\/i><\/a><\/li>\n<li><a href=\"https:\/\/depts.washington.edu\/comply\/docs\/102_F1.pdf\" target=\"_blank\" rel=\"noopener noreferrer\" data-kmt=\"1\">Agreement for Electronic Access to Protected Health Information \u2013 102.F1<i class=\"fa fa-file-pdf-o\"><\/i><\/a><\/li>\n<li><a href=\"https:\/\/depts.washington.edu\/comply\/docs\/104f13_AmRq.pdf\" target=\"_blank\" rel=\"noopener noreferrer\" data-kmt=\"1\">Amendment Request (UH2078) \u2013 104.F13<i class=\"fa fa-external-link\"><\/i><\/a><\/li>\n<li><a href=\"https:\/\/depts.washington.edu\/comply\/docs\/307_F1.pdf\" target=\"_blank\" rel=\"noopener\">Data Use Agreement for Use with University of Washington Recipients \u2013 (307.F1)<\/a><\/li>\n<li><a href=\"https:\/\/depts.washington.edu\/comply\/docs\/307_F2.pdf\" target=\"_blank\" rel=\"noopener\">Data Use Agreement for Use with Non-University of Washington Recipients \u2013 (307.F2)<\/a><\/li>\n<li><a href=\"https:\/\/depts.washington.edu\/comply\/docs\/002_F2.pdf\" target=\"_blank\" rel=\"noopener\">Protecting Patient Information Training Self-Study \u2013 002.F2 (Paper version<i class=\"fa fa-file-pdf-o\"><\/i>)<\/a><\/li>\n<li><a href=\"https:\/\/one.uwmedicine.org\/sites\/uwm-formsrep\/FormsLibrary\/U1868.pdf\" target=\"_blank\" rel=\"noopener noreferrer\" data-kmt=\"1\">Patient Information for Inclusion in the UW Medicine Patient Directory (UH1868) \u2013 103.F4<i class=\"fa fa-external-link\"><\/i><\/a><\/li>\n<li><a href=\"https:\/\/one.uwmedicine.org\/sites\/uwm-formsrep\/FormsLibrary\/U2883.pdf\" target=\"_blank\" rel=\"noopener noreferrer\" data-kmt=\"1\">Mandatory Violent Injury Report (UH2883) \u2013 103.F1<i class=\"fa fa-external-link\"><\/i><\/a><\/li>\n<li><a href=\"https:\/\/depts.washington.edu\/comply\/docs\/102_F3.pdf\" target=\"_blank\" rel=\"noopener noreferrer\" data-kmt=\"1\">Non-UW Medicine Workforce Privacy, Confidentiality and Information Security Agreement \u2013 102.F3<i class=\"fa fa-file-pdf-o\"><\/i><\/a><\/li>\n<li><a href=\"https:\/\/depts.washington.edu\/comply\/docs\/104f9_NPriAck.pdf\" target=\"_blank\" rel=\"noopener noreferrer\" data-kmt=\"1\">Notice of Privacy Practices Acknowledgment Form (UH2045) \u2013 104.F9<i class=\"fa fa-external-link\"><\/i><\/a><\/li>\n<li><a href=\"https:\/\/depts.washington.edu\/comply\/docs\/103f12_PtAuthPub.pdf\" target=\"_blank\" rel=\"noopener noreferrer\" data-kmt=\"1\">Patient Authorization for UW Medicine to Use or Disclose Protected Health Information for Publicity Form (UH1874) \u2013 103.F12<\/a><\/li>\n<li><a href=\"https:\/\/depts.washington.edu\/comply\/docs\/103f7_AuthRq.pdf\" target=\"_blank\" rel=\"noopener noreferrer\" data-kmt=\"1\">Patient Authorization to Disclose, Release and\/or Obtain Protected Health Information Form (UH0626) \u2013 103.F7<i class=\"fa fa-external-link\"><\/i><\/a><\/li>\n<li><a href=\"https:\/\/depts.washington.edu\/comply\/docs\/103f10_PtAuthPublicat.pdf\" target=\"_blank\" rel=\"noopener noreferrer\" data-kmt=\"1\">Patient Authorization to Use &amp; Disclose Protected Health Information for Publication (UH3031) \u2013 103.F10<i class=\"fa fa-external-link\"><\/i><\/a><\/li>\n<li><a href=\"https:\/\/depts.washington.edu\/comply\/docs\/103f11_PtAuthVid.pdf\" target=\"_blank\" rel=\"noopener noreferrer\" data-kmt=\"1\">Patient Authorization to Use or Disclose Photography\/Video Tape Form (UH0324) \u2013 103.F11<i class=\"fa fa-external-link\"><\/i><\/a><\/li>\n<\/ul>\n<\/div>\n<\/div>\n<div class=\"su-column su-column-size-1-2\">\n<div class=\"su-column-inner su-u-clearfix su-u-trim\">\n<ul>\n<li><a href=\"https:\/\/depts.washington.edu\/comply\/docs\/002_F1.pdf\" target=\"_blank\" rel=\"noopener noreferrer\" data-kmt=\"1\">Privacy, Confidentiality, and Information Security Agreement (PCISA) \u2013 002.F1<\/a><\/li>\n<li><a href=\"https:\/\/depts.washington.edu\/comply\/docs\/304_F1.pdf\" target=\"_blank\" rel=\"noopener\">Request for Approval for Use of Audio Recordings for Research, Education or Quality Improvement Purposes \u2013 304.F1<\/a><i class=\"fa fa-file-word-o\"><\/i><\/li>\n<li><a href=\"https:\/\/depts.washington.edu\/comply\/docs\/104f10_ReqPrivProtPHI.pdf\" target=\"_blank\" rel=\"noopener noreferrer\" data-kmt=\"1\">Request to Consider Additional Privacy Protection for Protected Health Information (UH1869) \u2013 104.F10<\/a><\/li>\n<li><a href=\"https:\/\/depts.washington.edu\/comply\/docs\/104f11_ReqPtSPay.pdf\" target=\"_blank\" rel=\"noopener noreferrer\" data-kmt=\"1\">Request to Restrict Disclosure of Health Care Items or Services to Health Plans When Patients Self Pay Out-of-Pocket (UH2923) \u2013 104.F11<i class=\"fa fa-external-link\"><\/i><\/a><\/li>\n<li><a href=\"https:\/\/www.uwmedicine.org\/about\/about-notice-of-privacy-practices-arabic.pdf\" target=\"_blank\" rel=\"noopener noreferrer\" data-kmt=\"1\">Translation NoPP: Arabic \u2013 104.F3<i class=\"fa fa-external-link\"><\/i><\/a><\/li>\n<li><a href=\"https:\/\/www.uwmedicine.org\/about\/about-notice-of-privacy-practices-chinese.pdf\" target=\"_blank\" rel=\"noopener noreferrer\" data-kmt=\"1\">Translation NoPP: Chinese \u2013 104.F4<i class=\"fa fa-external-link\"><\/i><\/a><\/li>\n<li><a href=\"https:\/\/www.uwmedicine.org\/about\/about-notice-of-privacy-practices-russian.pdf\" target=\"_blank\" rel=\"noopener noreferrer\" data-kmt=\"1\">Translation NoPP: Russian \u2013 104.F5<i class=\"fa fa-external-link\"><\/i><\/a><\/li>\n<li><a href=\"https:\/\/www.uwmedicine.org\/about\/about-notice-of-privacy-practices-somali.pdf\" target=\"_blank\" rel=\"noopener noreferrer\" data-kmt=\"1\">Translation NoPP: Somali \u2013 104.F6<i class=\"fa fa-external-link\"><\/i><\/a><\/li>\n<li><a href=\"https:\/\/www.uwmedicine.org\/about\/about-notice-of-privacy-practices-spanish.pdf\" target=\"_blank\" rel=\"noopener noreferrer\" data-kmt=\"1\">Translation NoPP: Spanish \u2013 104.F7<i class=\"fa fa-external-link\"><\/i><\/a><\/li>\n<li><a href=\"https:\/\/www.uwmedicine.org\/about\/about-notice-of-privacy-practices-vietnamese.pdf\" target=\"_blank\" rel=\"noopener noreferrer\" data-kmt=\"1\">Translation NoPP: Vietnamese \u2013 104.F8<i class=\"fa fa-external-link\"><\/i><\/a><\/li>\n<li><a href=\"https:\/\/one.uwmedicine.org\/sites\/uwm-formsrep\/FormsLibrary\/U1858.pdf\" target=\"_blank\" rel=\"noopener noreferrer\" data-kmt=\"1\">UW Medicine Joint Notice of Privacy Practices (Brochure) (UH1858)- 104.F1<i class=\"fa fa-external-link\"><\/i><\/a> [requires AMC login]<\/li>\n<li><a href=\"https:\/\/one.uwmedicine.org\/sites\/uwm-formsrep\/FormsLibrary\/U1866.pdf\" target=\"_blank\" rel=\"noopener noreferrer\" data-kmt=\"1\">Verbal Redisclosure (Record of Verbal Redisclosure of PHI) (UH1866) \u2013 103.F9<\/a><\/li>\n<li><a href=\"https:\/\/depts.washington.edu\/comply\/docs\/102_F2.pdf\" target=\"_blank\" rel=\"noopener noreferrer\" data-kmt=\"1\">Workforce Member Documentation of IT System Access \u2013 102.F2<i class=\"fa fa-file-pdf-o\"><\/i><\/a><\/li>\n<\/ul>\n<\/div>\n<\/div>\n<\/div>\n<h2><strong>Guidance<\/strong><\/h2>\n<div class=\"su-row\">\n<div class=\"su-column su-column-size-1-2\">\n<div class=\"su-column-inner su-u-clearfix su-u-trim\">\n<ul>\n<li style=\"list-style-type: none;\">\n<ul>\n<li><a href=\"https:\/\/depts.washington.edu\/comply\/docs\/202_G1.pdf\" target=\"_blank\" rel=\"noopener noreferrer\" data-kmt=\"1\">Billing Entity Site of Practice \u2013 202.G1<i class=\"fa fa-file-pdf-o\"><\/i><\/a><\/li>\n<li><a href=\"https:\/\/depts.washington.edu\/comply\/docs\/005_G1.pdf\" target=\"_blank\" rel=\"noopener noreferrer\" data-kmt=\"1\">Compliance Investigations: Standard Operating Procedures \u2013 005.G1<i class=\"fa fa-file-pdf-o\"><\/i><\/a><\/li>\n<li><a href=\"http:\/\/depts.washington.edu\/comply\/docs\/102_G2.pdf\" target=\"_blank\" rel=\"noopener noreferrer\" data-kmt=\"1\">Faxing PHI \u2013 102.G2\u00a0<i class=\"fa fa-file-pdf-o\"><\/i><\/a><\/li>\n<li><a href=\"https:\/\/depts.washington.edu\/comply\/docs\/103_G3.pdf\" target=\"_blank\" rel=\"noopener noreferrer\" data-kmt=\"1\">Law Enforcement Requests Disclosure of Patient Information \u2013 103.G3<i class=\"fa fa-file-pdf-o\"><\/i><\/a><\/li>\n<li><a href=\"https:\/\/depts.washington.edu\/comply\/docs\/103_G9.pdf\" target=\"_blank\" rel=\"noopener noreferrer\" data-kmt=\"1\">Marketing Activities Guidance \u2013 103.G9<i class=\"fa fa-file-pdf-o\"><\/i><\/a><\/li>\n<li><a href=\"https:\/\/depts.washington.edu\/comply\/docs\/103_G2.pdf\" target=\"_blank\" rel=\"noopener noreferrer\" data-kmt=\"1\">Minimum Necessary Disclosure Decision Tree \u2013 103.G2<i class=\"fa fa-file-pdf-o\"><\/i><\/a><\/li>\n<li><a href=\"https:\/\/depts.washington.edu\/comply\/docs\/304_G1.pdf\" target=\"_blank\" rel=\"noopener\">Photography and Audiovisual Recording in the Clinical Setting \u2013 FAQ \u2013 304.G1<\/a><\/li>\n<li><a href=\"https:\/\/depts.washington.edu\/comply\/docs\/101_G2.pdf\" target=\"_blank\" rel=\"noopener noreferrer\" data-kmt=\"1\">Privacy Policies Summary \u2013 101.G2<\/a><\/li>\n<li><a href=\"https:\/\/depts.washington.edu\/comply\/docs\/103_G8.pdf\" target=\"_blank\" rel=\"noopener noreferrer\" data-kmt=\"1\">Release of PHI for Judicial and Administrative proceedings \u2013 103.G8<i class=\"fa fa-file-pdf-o\"><\/i><\/a><\/li>\n<li><a href=\"https:\/\/depts.washington.edu\/comply\/docs\/103_G7.pdf\" target=\"_blank\" rel=\"noopener noreferrer\" data-kmt=\"1\">Prohibition on Redisclosure \u2013 103.G7<i class=\"fa fa-file-pdf-o\"><\/i><\/a><\/li>\n<li><a href=\"http:\/\/depts.washington.edu\/comply\/docs\/102_G4.pdf\" target=\"_blank\" rel=\"noopener noreferrer\" data-kmt=\"1\">Protected Health Information (PHI) \u2013 102.G4<\/a><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/div>\n<\/div>\n<div class=\"su-column su-column-size-1-2\">\n<div class=\"su-column-inner su-u-clearfix su-u-trim\">\n<ul>\n<li><a href=\"https:\/\/depts.washington.edu\/comply\/docs\/303_G1.pdf\" target=\"_blank\" rel=\"noopener noreferrer\" data-kmt=\"1\">Social Media Guidance \u2013 303.G1<\/a><\/li>\n<li><a href=\"https:\/\/depts.washington.edu\/comply\/docs\/103_G1.pdf\" target=\"_blank\" rel=\"noopener noreferrer\" data-kmt=\"1\">Treatment, Payment and Healthcare Operations \u2013 103.G1<i class=\"fa fa-file-pdf-o\"><\/i><\/a><\/li>\n<li><a href=\"https:\/\/depts.washington.edu\/comply\/docs\/101_G1.pdf\" target=\"_blank\" rel=\"noopener noreferrer\" data-kmt=\"1\">University of Washington HIPAA Designation \u2013 101.G1<i class=\"fa fa-file-pdf-o\"><\/i><\/a><\/li>\n<li><a href=\"https:\/\/depts.washington.edu\/comply\/docs\/005_G2.pdf\" target=\"_blank\" rel=\"noopener noreferrer\" data-kmt=\"1\">UWP, Addressing Reported Concerns Procedure \u2013 005.G2<i class=\"fa fa-file-pdf-o\"><\/i><\/a><\/li>\n<li><a href=\"https:\/\/depts.washington.edu\/comply\/docs\/203_G1.pdf\" target=\"_blank\" rel=\"noopener noreferrer\" data-kmt=\"1\">UWP Timely Documentation for Billing Purposes Exceptions: Standard Operating Procedures \u2013 203.G1<i class=\"fa fa-file-pdf-o\"><\/i><\/a><\/li>\n<li><a href=\"https:\/\/depts.washington.edu\/comply\/docs\/103_G10.pdf\" target=\"_blank\" rel=\"noopener noreferrer\" data-kmt=\"1\">Use &amp; Disclosure of PHI for Involvement in Patient\u2019s Care and Notification Decision Tree \u2013 103.G10<i class=\"fa fa-file-pdf-o\"><\/i><\/a><\/li>\n<li><a href=\"https:\/\/depts.washington.edu\/comply\/docs\/308_G1.pdf\" target=\"_blank\" rel=\"noopener\">UW Medicine Artificial Intelligence (AI) Policy Glossary \u2013 308.G1\u00a0<\/a><\/li>\n<li><a href=\"https:\/\/depts.washington.edu\/comply\/docs\/Glossary.pdf\" target=\"_blank\" rel=\"noopener noreferrer\" data-kmt=\"1\">UW Medicine Compliance Glossary \u2013 GDN_M_Compliance Glossary<i class=\"fa fa-file-pdf-o\"><\/i><\/a><\/li>\n<li><a href=\"https:\/\/www.uwmedicine.org\/about\/policies-and-notices\/wearable-technology-guidance\" target=\"_blank\" rel=\"noopener noreferrer\" data-kmt=\"1\">Wearable Tech Guidance \u2013 GDN_M_WearableTechnology<i class=\"fa fa-external-link\"><\/i><\/a><\/li>\n<\/ul>\n<\/div>\n<\/div>\n<\/div>\n<h2><strong>Templates<\/strong><\/h2>\n<div class=\"su-row\">\n<div class=\"su-column su-column-size-1-2\">\n<div class=\"su-column-inner su-u-clearfix su-u-trim\">\n<ul>\n<li><a href=\"https:\/\/depts.washington.edu\/comply\/docs\/103_T6.docx\" target=\"_blank\" rel=\"noopener noreferrer\" data-kmt=\"1\">Data Use Agreement for Limited Data Set (for individuals or entities NOT part of UW Medicine workforce) \u2013 103.T6<i class=\"fa fa-external-link\"><\/i><\/a><\/li>\n<li><a href=\"https:\/\/depts.washington.edu\/comply\/docs\/103_T7.docx\" target=\"_blank\" rel=\"noopener noreferrer\" data-kmt=\"1\">Data Use Agreement for Limited Data Set for UW Medicine workforce \u2013 103.T7<i class=\"fa fa-external-link\"><\/i><\/a><\/li>\n<\/ul>\n<\/div>\n<\/div>\n<div class=\"su-column su-column-size-1-2\">\n<div class=\"su-column-inner su-u-clearfix su-u-trim\">\n<ul>\n<li><a href=\"https:\/\/depts.washington.edu\/comply\/docs\/106_T1.docx\" target=\"_blank\" rel=\"noopener noreferrer\" data-kmt=\"1\">UW Medicine Business Associate Agreement \u2013 106.T1<i class=\"fa fa-external-link\"><\/i><\/a><\/li>\n<\/ul>\n<\/div>\n<\/div>\n<\/div>\n","protected":false},"excerpt":{"rendered":"<p>Forms Guidance Templates<\/p>\n<div><a class=\"more-link\" href=\"https:\/\/depts.washington.edu\/comply\/policy-resources\/\">Continue reading <span class=\"screen-reader-text\">Policy Guidance, Forms &#038; Templates<\/span><\/a><\/div>\n","protected":false},"author":11,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_monsterinsights_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"footnotes":""},"class_list":["post-7924","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/depts.washington.edu\/comply\/wp-json\/wp\/v2\/pages\/7924","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/depts.washington.edu\/comply\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/depts.washington.edu\/comply\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/depts.washington.edu\/comply\/wp-json\/wp\/v2\/users\/11"}],"replies":[{"embeddable":true,"href":"https:\/\/depts.washington.edu\/comply\/wp-json\/wp\/v2\/comments?post=7924"}],"version-history":[{"count":50,"href":"https:\/\/depts.washington.edu\/comply\/wp-json\/wp\/v2\/pages\/7924\/revisions"}],"predecessor-version":[{"id":9109,"href":"https:\/\/depts.washington.edu\/comply\/wp-json\/wp\/v2\/pages\/7924\/revisions\/9109"}],"wp:attachment":[{"href":"https:\/\/depts.washington.edu\/comply\/wp-json\/wp\/v2\/media?parent=7924"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}