*** Content Under Review ***  

*** See www.compliance.wisc.edu/hipaa for up-to-date content. ***

The UW-Madison HIPAA Compliance Program is updating policies, forms, FAQs, and guidelines to better serve your needs.  Additionally -- we are migrating content from these pages to www.compliance.wisc.edu/hipaa; once we complete the migration, this site will retire and visitors to these pages will be re-directed to that location.  Thank you in advance for your patience! 

Please forward your website improvement suggestions to hipaa@wisc.edu.   


The forms below are also available from the "Policies" tab.  For additional HIPAA forms used in research, see the Forms section within the "For Researchers" tab.

Access to Protected Health Information


Acknowledgement for Receipt of Notice of Privacy Practices

Authorizations and Related Instructions

Authorization for Disclosure of Medical Information (General Purpose)

Instructions for Staff for Completing Authorization for Disclosure 
Authorization for Disclosure of Medical Information for Publication

Authorization for Use or Disclosure of Medical Information for Marketing or Fundraising

Breaches of Unsecured Protected Health Information
Privacy Incident Report Form

Contracts and Related Forms

Data Use Agreement for Disclosure of a Limited Data Set

Business Associate Agreement

Certification that PHI Destroyed or Destruction Infeasible

Checklist for UW-Madison Business Associates

Patient Complaints

Patient Requests


  • Accounting of Disclosures


Sample Disclosure Tracking Log

Sample Request for Accounting of Disclosures

Sample Reports of Disclosures to Third Parties


  • Alternative Confidential Communications


Alternative Confidential Communication Request Form 

Letter Accepting Individual’s Request for Alt. Confidential Communications

Letter Denying Individual’s Request for Alt. Confidential Communications 


  • Amendment of Protected Health Information


Sample Request for Amendment of Health Information

Sample Request for Notification of Amendment

Sample Letter Notifying of Need for 30 Day Extension

Sample Letter Accepting Amendment

Sample Letter Denying Amendment

Sample Letter Responding to Statement of Disagreement


  • Inspection and Copying of Protected Health Information


Sample Letter Notifying of Need for 30 Day Extension

Sample Letter Denying Request to Obtain a Copy of PHI


  • Restrictions on Uses and Disclosures of Protected Health Information


Request for Restrictions on Use/Disclosure of PHI 

Sample Letter of Approval of Request for Restrictions

Sample Letter of Denial of Request for Restrictions

Security Related

Fax Transmission Cover Sheet

Provider – Patient E-mail Information and Consent

Guidelines for Using E-mail


Sample Certificate of Destruction of Protected Health Information






HIPAA Privacy Officer

Amanda K. Reese

4170 Health Sciences Learning Center
750 Highland Avenue
Madison, WI 53705

(608) 262-2059


HIPAA Security Officer

Stefan Wahe 

Room 2164 Computer Science & Statistics
1210 W. Dayton Street
Madison, WI 53706

(608) 265-1177


Anonymous Hotline (Anonymous Human Research Protection Hotline):

To report an IT security incident or loss of sensitive data call the DoIT Help Desk: 
608-264-HELP (4357)