HIPAA Forms|HIPAA Patient Disclosure Authorization Form

HIPAA Forms
Blank or Personalized with your name, address, city, state, zip code and telephone number.

HIPAA Forms Up to 40% Less than our Competitors

Notice of Privacy Practices

Stock 20 lb. White Bond
Imprinted up to 5 lines plus effective date and privacy officer name
Printed 1 color Black Ink, 2 sides. Size: 8-1/2" x 11"

Form No. NPP-1IMP Price per lot Personalized Notice of Privacy Practice

500	1000	2500
$112.00	$ 129.00	$210.00

Form No. NPP-1BL Price per 100 sheets Not Personalized Notice of Privacy Practice

200	400	800	1600	2400
$ 19.00	$17.00	$15.00	$14.00	$10.00

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Patient Acknowledgement

1 Part - Stock 20 lb. White Bond
Imprinted up to 5 lines
Printed 1 color Black Ink Size: 8-1/2" x 11"
Punched 2 round holes 1/4" - 2-3/4" centers

Form No. NPPA-1IMP (1 Part) Price per lot Personalized

500	1000	2500
$ 69.00	$ 95.00	$175.00

Form No. NPPA-1BL (1 Part) Price per 100 Not Personalized

200	400	800	1600	2500
$ 10.00	$9.00	$8.00	$7.00	$6.00

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Patient Records Access Form

1 Part - Stock 20 lb. White Bond
Imprinted up to 5 lines
Printed 1 color Black Ink, Size: 8-1/2" x 11"
Punched 2 round holes 1/4" - 2-3/4" centers

Form No. PRAF-1IMP (1 Part) Price per lot Personalized

500	1000	2500
$ 69.00	$ 95.00	$175.00

Form No. PRAF-1BL(1 Part) Price per 100 Not Personalized

200	400	800	1600	2500
$ 10.00	$9.00	$8.00	$7.00	$6.00

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Individual Patient Disclosure Authorization Form

1 Part - Stock 20 lb. White Bond
Imprinted up to 5 lines
Printed 1 color Black Ink,. Size: 8-1/2" x 11"
Punched 2 round holes 1/4" - 2-3/4" centers

Form No. DISC-1IMP (1 Part) Price per lot Personalized

500	1000	2500
$ 69.00	$ 95.00	$175.00

Form No. DISC-1BL(1 Part) Price Per 100 Not Personalized

200	400	800	1600	2500
$ 10.00	$9.00	$8.00	$7.00	$6.00

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Complaint Form

1 Part - Stock 20 lb. White Bond
Imprinted up to 5 lines
Printed 1 color Black Ink, Size: 8-1/2" x 11"
Punched 2 round holes 1/4" - 2-3/4" centers

Form No. COMP-1IMP (1 Part) Price per lot Personalized

500	1000	2500
$ 69.00	$ 95.00	$175.00

Form No. COMP-1BLK (1 Part) Price per 100 Not Personalized

200	400	800	1600	2500
$ 10.00	$9.00	$8.00	$7.00	$6.00

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Report of Non-Routine Disclosures

1 Part - Stock 20 lb. White Bond
Imprinted up to 5 lines
Printed 1 color Black Ink, Size: 8-1/2" x 11"
Punched 2 round holes 1/4" - 2-3/4" centers

Form No. NON-1IMP (1 Part) Price per lot Personalized

500	1000	2500
$ 69.00	$ 95.00	$175.00

Form No. NON-1BL (1 Part) Price per 100 Not Personalized

200	400	800	1600	2500
$ 10.00	$9.00	$8.00	$7.00	$6.00

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Here's a simple answer to
patient confidentiality at sign in.

In 1996, Congress passed the Health Insurance Portability and Accountability Act (HIPAA), that mandates new ways to handle patient information that will protect privacy. One option developed protects privacy at sign-in where the identity of each patient is kept confidential.

With this simple, affordable method of sign-in in place, patients can't see other patients names and information. What's more office personnel can refer to patients either by name or number.

On a numbered slip, each patient prints Name, Arrival Time, Name of Healthcare Professional and lets the office know of any insurance or address changes since the last visit. The information is transferred via carbonless paper to a a master log. Once the patient removes the slip, the information is protected behind the carbonless paper, available only for office use.

The front desk attendant reads the log and each patient is called by name or number.

Each kit contains 40 sets, numbered 1 through 25.
Enough for 1000 patients

Form No. W-SGNKIT with binder (List $95.00)

1	2 - 5
$ 81.75 ea	$ 76.00 ea

Form No. W-JSGN Refill Kits no binder (List 59.90)

1 - 4	5 +
$ 51.50 ea	$ 47.00 ea

Custom Sign-in Sheets made to your requirements
Call DRSforms-systems.com
Toll Free: 1-866-696-0800
NY State Residents: 1-631-696-4900
Fax: 1-631-696-4901

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