HIPAA Privacy Act Sample Forms
The HIPAA Privacy Act requires the implementation of several key documents. The documents herein are examples that policyholders may adapt to
become HIPAA compliant. The Privacy Policy Prototype and HIPAA forms are provided
as general guidance and do not constitute legal advice. All forms were developed by the
Physician Insurers Association of America's HIPAA Taskforce and are provided
with permission from that organization. For answers to questions not addressed in
the prototype and forms, please contact the Centers for Medicare and Medicaid Services
www.cms.hhs.gov/hippa, your county medical society, or the other resources
listed in MIEC's Special Report Claims Alert
#34.
Do not attempt to edit HIPAA forms while in MIEC's website. Save the
document to your computer and edit offline.
MIEC HIPAA “Starter Kit”
For a Small or Solo Medical Practice
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