Home > For Patients > HIPAA > HIPAA Forms

HIPAA Forms

Clients Rights
HIPAA
   HIPAA Forms

          Request for Access to Health Information
          Request for Amendment to Health Information
          Request to Restrict Confidential Communication
          Request to Restrict Use & Disclosure of Health Information
​          Request to Opt Out of Clinisync Health Information Exchange

For More Information Please Contact:

                       Diane S. DeRue, MPA, LSW
                       Vice President/Chief of Recovery Services
                       Corporate Compliance and Privacy Officer

                       (330) 264-9029
                       dsderue@ccwhc.org