The Counseling Center

of Wayne and Holmes Counties

 

Est. 1953 ~ Over 50 years of service excellence!

HIPAA-- Health Insurance Portability and Accountability Act

       

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n  Request Limits on Uses and Disclosures of Your PHI Form
n Choose How We Send PHI to You Form
n See and Get Copies of your PHI Form
n Correct or Update your PHI Form

Directions for printing the  HIPAA forms.

 

Click on the form request button. When the form appears, click on the Print button in the task bar of your Internet browser. If your print button does not work please us the following steps.

 

Step 1.  Right click on the mouse and in the menu that appears, left click on the "Select All" option.   

Step 2. When the text is highlighted, right click on the mouse once again and in the menu that  appears, left click on the "Copy" option.

Step 3. Right click on the mouse and in the menu that appears, left click on the "Print" option.

 

Forms to request changes, corrections and/or copies of your clinical record are also available from the Corporate Compliance and Privacy Officer, Medical Records or any Counseling Center office.

FOR MORE INFORMATION ABOUT FORMS

If you have any questions about printing and/or submitting forms, please contact:

 

Diane S. DeRue, MPA, LSW

Compliance and Privacy Officer

2285 Benden Drive

Wooster, Ohio 44691

(330) 264-9029.

dderue@ccwhc.org