HIPAA Application Forms

Application Forms

Forms for access to materials protected by the Health Insurance Portability and Accountability Act (HIPAA)

• Healthcare Operations, Form A
  Only members of the workforce of the Johns Hopkins Medical Institutions or its business associates are eligible to request access for operational purposes.
• Application for Access for Research on Decedents, Form B
  This application form is to request access to materials that may contain individually identifiable health information of individuals who are presumed to be deceased.
• Application for Access for Reviews Preparatory to Research, Form C
  This application form is to request access to materials solely to prepare for a research activity or for similar purposes preparatory to research.
• Individual Privacy Authorization, Form D-1
  This application form is for individuals (or their personal representatives) to authorize release of health information.
• Application for Waiver of Authorization from the Privacy Board, Form D-2
  This application form is to request a Waiver of Authorization from the Privacy Board of the Johns Hopkins Medical Institutions if it is not practicable to obtain Individual Privacy Authorization from each individual represented in a collection of materials.
• Application for an Amendment to an Existing Waiver of Authorization from the JHMI Privacy Board, Form D-3
  This application form is for current holders of Waivers of Authorization from the Privacy Board of the Johns Hopkins Medical Institutions. You may apply for an Amendment to request changes to your Waiver of Authorization, such as to add or remove co-investigators; to adjust the design and scope of your project; to amend plans for protection of data and information. Holders of Waivers of Authorization issued before September 23, 2013 can request amendments to allow use of individually identifiable health information that is not part of the medical record as defined by Maryland Health Code 4-302 (2013) provided that the individual has been deceased for more than fifty years.