HIPAA sign-in forms

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HIPAA COMPLIANT CONFIDENTIAL PATIENT SIGN-IN SYSTEM
(HIP01)


HIPAA CONFIDENTIAL PATIENT SIGN-IN SHEETS WITH ADHESIVE STRIPS
(HIP02) Blue
(HIP02GN) Green
(HIP02BY) Burgundy
(HIP04) Bi-Lingual, English/Spanish

HIPAA CONFIDENTIAL PATIENT SIGN-IN SHEETS
GENERIC
(HIP03)

HIPAA CONFIDENTIAL PATIENT SIGN-IN SHEETS
NON-MEDICAL
(HIP05)

HIPAA Employee Training Record
HIPAA Form #101

HIPAA Practice Training Record
HIPAA Form #102

Protected Health Information (PHI) Access Log
HIPAA Form #103

Protected Health Information (PHI)
Disclosure Log
HIPAA Form #104

Patient Request for Amendment of
Health Information
HIPAA Form #105

Patient Requests for Accounting of Disclosures
HIPAA Form #106

Patient Request to Inspect / Review PHI
HIPAA Form #107

Patient Request for Confidential
Communications
HIPAA Form #108

Patient Request for Restrictions on Use
& Disclosure of PHI
HIPAA Form #109

Protected Health Insurance (PHI) Tracking Log
HIPAA Form #110

Authorization to Release Information
HIPAA Form #111

Notice of Privacy Practices
HIPAA Form #120

Notice of Privacy Practices
Spanish Version
HIPAA Form #120S

HIPAA INFORMATION

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HIPAA Compliant Confidential Patient Sign-In System (HIP01)

For an Easy Tour of how the HIP01 Sign-In System
works Sheet by Sheet
Click Here

At patient sign-in

Make one HIPAA
privacy worry

Only $51.00/package
Enough for 1000 Patients
Each package contains 40 sets. Each set has 25 slips so one package will be sufficient for 1,000 patients.  The pegboard binders are reusable and are designed specifically for use with our HIP01 patient sign-in system.

Description

Sets/Pack

Price/Pack

Confidential
Patient
Sign-In
System
(HIP01)
(without binder)

40 sets
for 1,000 patients

$51.00

Binder
Compatible with HIP01 Only
Click Here
to See Image

1 Binder

$50.00

You can also order by Phone

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TOLL FREE AT:
1-877-840-1500
Our Office Hours ar
8-5 Mon.-Fri. CST

HIPAA CONFIDENTIAL PATIENT SIGN-IN SHEETS
WITH ADHESIVE PEEL-OFF STRIPS
(HIP02)

  Our most popular HIPAA form, HIP02, now comes in 3 colors!
and a
Bi-Lingual, English/Spanish Version (Blue Only)

Our HIPAA compliant sign-in form HIP02 is now available in three colors. The standard background color is blue, but green and burgundy are also available at no extra cost. This is a great option for multiple office locations or departments.

How it works: Each of the 25 signature lines is an adhesive label. The labels are numbered 1-25. When the patient signs in, the information is transferred through a carbonless sheet to a patient log sheet on the back of the form for the desk attendant to access. The attendant then peels off the label revealing an information blocking sheet that says "Please Use Next Line". This new feature guides the next patient to sign in on the appropriate line. The label can then be removed and attached to the patient's file to keep a history of his or her visits.  No information is visible to the patients.

Each pack contains 125 sign-in forms enough to see 3,125 patients!

 

HIPAA CONFIDENTIAL PATIENT SIGN-IN SHEETS
WITH ADHESIVE PEEL-OFF STRIPS
(HIP02) BLUE (Standard Color)

Tell Me How It Works
CLICK HERE

Description

Quantity/Case

Price/Case

Secure Order

Confidential Sign In Log
with Adhesive Peel-Off Strips
(HIP02)
Blue

125

$49.95

You can also order by Phone

CALL US
TOLL FREE AT:
1-877-840-1500
Our Office Hours ar
8-5 Mon.-Fri. CST

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HIPAA CONFIDENTIAL PATIENT SIGN-IN SHEETS
WITH ADHESIVE PEEL-OFF STRIPS
(HIP02GN) GREEN

Tell Me How It Works
CLICK HERE

Description

Quantity/Case

Price/Case

Secure Order

Confidential Sign In Log
with Adhesive Peel-Off Strips
(HIP02GN)
Green

125

$49.95

You can also order by Phone

CALL US
TOLL FREE AT:
1-877-840-1500
Our Office Hours ar
8-5 Mon.-Fri. CST

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HIPAA CONFIDENTIAL PATIENT SIGN-IN SHEETS
WITH ADHESIVE PEEL-OFF STRIPS
(HIP02BY) BURGUNDY

Tell Me How It Works
CLICK HERE

Description

Quantity/Case

Price/Case

Secure Order

Confidential Sign In Log
with Adhesive Peel-Off Strips
(HIP02BY)
Burgundy

125

$49.95

You can also order by Phone

CALL US
TOLL FREE AT:
1-877-840-1500
Our Office Hours ar
8-5 Mon.-Fri. CST

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HIPAA CONFIDENTIAL PATIENT SIGN-IN SHEETS
GENERIC (HIP03)

Our HIP03 Generic Sign-In form is not geared specifically toward medical practices, but is designed to be used by any type of business that requires confidentiality for their clients. Non-medical clinics such as weight-loss, law offices and secure military offices are just some of the businesses that can benefit from using this form.

The HIP03 Generic Sign-In form has 20 peel-off signature lines. It works exactly like the HIP02 by transferring the visitor's information to the log sheet on the back of the form. Once the signature label is removed the information can only be seen by the desk attendant.

 HIP03 comes in boxes of 200 forms.

Description

Quantity/Case

Price/Case

Secure Order

Confidential Sign In Log
Generic
(HIP03)

200

$80.00

You can also order by Phone

CALL US
TOLL FREE AT:
1-877-840-1500
Our Office Hours ar
8-5 Mon.-Fri. CST

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HIPAA CONFIDENTIAL PATIENT SIGN-IN SHEETS WITH ADHESIVE PEEL-OFF STRIPS (HIP04) BI-LINGUAL (English/Spanish), BLUE ONLY

Tell Me How It Works
CLICK HERE

Description

Quantity/Case

Price/Case

Secure Order

Confidential Sign In Log
with Adhesive Peel-Off Strips
(HIP04)
Bi-Lingual
Blue Only

125

$49.95

You can also order by Phone

CALL US
TOLL FREE AT:
1-877-840-1500
Our Office Hours ar
8-5 Mon.-Fri. CST

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HIPAA CONFIDENTIAL PATIENT SIGN-IN SHEETS
WITH ADHESIVE PEEL-OFF STRIPS
NON MEDICAL SIGN-IN FORM (HIP05)

An alternative to our Generic Sign In Form. The HIP05 is a basic sign in form, easily completed by the user while protecting their privacy. Perfect for offices that do not require insurance information. The form works exactly like the HIP02 with 25 peel-off adhesive strips on each form. The information entered by the user is transferred to the log sheet on the back of the form which prevents the next user access to the information once the label is peeled off.

125 forms per pack

Description

Quantity/Case

Price/Case

Secure Order

Confidential Sign In Log
Non Medical
(HIP05)

125

$49.95

You can also order by Phone

CALL US
TOLL FREE AT:
1-877-840-1500
Our Office Hours ar
8-5 Mon.-Fri. CST

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HIPAA Compliant
Confidential
Patient Sign-In
System

At patient sign-in

Make one HIPAA
privacy worry

Stay HIPAA Compliant...with forms specially designed to meet HIPAA Requirements!

As of April 14, 2003 HIPAA requires that healthcare practices take certain steps, and provides for steep penalties for those that do not comply. Under HIPAA, Patients are now given new fundamental rights, including:

  • the right to inspect and/or obtain copies of their medical record
  • the right to request amendments to their record
  • the right to request restrictions on the disclosure of their protected health information
  • the right to ask practices to communicate with them in a certain manner
  • the right to ask practices for a log of who has accessed their protected health information

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

Our forms were created with the understanding that running a healthcare practice is a difficult job, and that added burdens practices can have serious negative effects. Best of all, the forms are easy to use, and will help meet the new federal requirements.

Use these forms to:
- Comply with Federal HIPAA Privacy Regulations
- Document & track information necessary to show that you are HIPAA compliant
- Integrate easily with your existing medical record system
- Help simplify administrative processes
- Ensure that patients privacy rights are not violated
 
More HIPAA Information    Prices and Ordering

 

HIPAA Employee Training Record (Form #101)

  A record of the HIPAA programs attended by the employee, number of hours attended, location, etc. Retain form in individual employees' personnel file.

Description

Pkg Qty

Price/Pack

HIPAA Employee Training Record Logs (Form #101)

25

$5.50

You can also order by Phone or Online:

CALL US
TOLL FREE AT:
1-877-840-1500
Our Office Hours ar
8-5 Mon.-Fri. CST

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forms online

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HIPAA Practice Training Record (Form #102)

  A record of each HIPAA educational program you provide for employees. Includes title of program, number of hours, and attendees. Retain form in your HIPAA Compliance Manual.

Description

Pkg Qty

Price/Pack

HIPAA Practice Training Record Logs (Form #102)

25

$5.50

You can also order by Phone or Online:

CALL US
TOLL FREE AT:
1-877-840-1500
Our Office Hours ar
8-5 Mon.-Fri. CST

Order HIPAA
forms online

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Protected Health Information (PHI) Access Log (Form #103)

  Allows you to track "uses" of PHI in each individual patient medical record. Form includes date, name and title of employee accessing the patient medical record and the reason for access.

Description

Pkg Qty

Price/Pack

Protected Health Information (PHI) Access Logs (Form #103)

250

$34.95

You can also order by Phone or Online:

CALL US
TOLL FREE AT:
1-877-840-1500
Our Office Hours ar
8-5 Mon.-Fri. CST

Order HIPAA
forms online

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Protected Health Information (PHI)
Disclosure Log
(Form #104)

  As required by HIPAA, you must track to whom disclosures of PHI are made. This form, retained in each patient's medical record, includes the pertinent information that should be recorded when disclosures are made. This form will be photocopied for patients who request an "Accounting of Disclosures."

Description

Pkg Qty

Price/Pack

Protected Health Information (PHI) Disclosure Logs (Form #104)

250

$34.95

You can also order by Phone or Online:

CALL US
TOLL FREE AT:
1-877-840-1500
Our Office Hours ar
8-5 Mon.-Fri. CST

Order HIPAA
forms online

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Patient Request for Amendment of
Health Information
(Form #105)

  The patient who requests that an amendment be made to his record will be asked to complete this request. It contains all elements necessary for the provider to make a decision to grant or deny the request. The form is retained in the patient's medical record.

Description

Pkg Qty

Price/Pack

Patient Request for Amendment of Health Information (Form #105)

100

$14.95

You can also order by Phone or Online:

CALL US
TOLL FREE AT:
1-877-840-1500
Our Office Hours ar
8-5 Mon.-Fri. CST

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forms online

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Patient Requests for Accounting of Disclosures (Form # 106)

  The patient who requests an "Accounting of Disclosures" will be asked to complete this form that requires the patient to provide the purpose of the requests, the dates requested, etc. The form, retained in the patient's medical record, also allows you to record the date you comply with the requests.

Description

Pkg Qty

Price/Pack

Patient Request for Accounting of Disclosures (Form #106)

100

$14.95

You can also order by Phone or Online:

CALL US
TOLL FREE AT:
1-877-840-1500
Our Office Hours ar
8-5 Mon.-Fri. CST

Order HIPAA
forms online

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Patient Request to Inspect / Review PHI (Form #107)

  The patient who requests to inspect or review protected health information will be asked to complete this form that requires the patient to provide information regarding which information and/or dates are being requested. The form, retained in the patient's medical record, also allows you to record when and how the records are reviewed, if the review is denied, the reason for the denial and the denial notification date.

Description

Pkg Qty

Price/Pack

Patient Request to Inspect Protected Health Information (Form #107)

100

$14.95

You can also order by Phone or Online:

CALL US
TOLL FREE AT:
1-877-840-1500
Our Office Hours ar
8-5 Mon.-Fri. CST

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forms online

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Patient Request for Confidential
Communications
(Form #108)

  The patient may request alternate means of communication. For example, a patient may request that they not be phoned at home or that mail be sent to an alternate address. In cases such as this, the patient will be asked to complete this form that requires the patient to outline specific communication requests.

Description

Pkg Qty

Price/Pack

Patient Request for Confidential Communications (Form #108)

100

$14.95

You can also order by Phone or Online:

CALL US
TOLL FREE AT:
1-877-840-1500
Our Office Hours ar
8-5 Mon.-Fri. CST

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forms online

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Patient Request for Restrictions on Use
& Disclosure of PHI
(Form #109)

  The patient who requested that all or part of his PHI be restricted through use (within your practice) or through disclosure (to outside entities) will complete this form. The patient will provide specific information on WHAT he wants restricted and FROM WHOM. The form, retained in the patient's medical record, allows you to record when and how this request is granted, denied and/or terminated.

Description

Pkg Qty

Price/Pack

Patient Request for Restrictions on Use & Disclosure of PHI (Form #109)

100

$14.95

You can also order by Phone or Online:

CALL US
TOLL FREE AT:
1-877-840-1500
Our Office Hours ar
8-5 Mon.-Fri. CST

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forms online

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Protected Health Insurance (PHI) Tracking Log (Form #110)

  This comprehensive log allows the practice to track the status of each request the patient may have made. It summarizes all forms that will be completed by the patient that are filed in the medical record: Request to Inspect/Copy, Request for Restrictions, Request for Confidential Communication, Request for Amendment, and Request for Accounting of Disclosures. The use of this log will eliminate the need to look through the entire record to determine if the patient has exercised any privacy rights. All information is on this one form.

Description

Pkg Qty

Price/Pack

Protected Health Insurance (PHI) Tracking Log (Form #110)

100

$14.95

You can also order by Phone or Online:

CALL US
TOLL FREE AT:
1-877-840-1500
Our Office Hours ar
8-5 Mon.-Fri. CST

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forms online

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Authorization to Release Information (Form #111)

  Protected health information may be disclosed without written authorization only in the purposes specifically outlined in the Notice of Privacy Practice. All other uses and disclosures require this form which the patient fills out for authorization.

Description

Pkg Qty

Price/Pack

Authorization to Release
Information (Form #111)

100

$31.95

You can also order by Phone or Online:

CALL US
TOLL FREE AT:
1-877-840-1500
Our Office Hours ar
8-5 Mon.-Fri. CST

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forms online

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Notice of Privacy Practices (Form #120)
(includes acknowledgement)

  Written Notice of Privacy Practices must be provided to patients on or before the first encounter and to other persons upon request. The Notice notifies the patient of all uses and disclosures of his or her protected health information. In addition, this form has a removable label that provides practices with a written acknowledgement that the patient received the Privacy Notice, as required to be HIPAA compliant.

Description

Pkg Qty

Price/Pack

Notice of Privacy Practices (Form #120) (includes acknowledgement)

250

$159.95

You can also order by Phone or Online:

CALL US
TOLL FREE AT:
1-877-840-1500
Our Office Hours ar
8-5 Mon.-Fri. CST

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forms online

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Notice of Privacy Practices Spanish Version (Form #120S)
(includes acknowledgement)

Spanish Version - Written Notice of Privacy Practices must be provided to patients on or before the first encounter and to other persons upon request. The Notice notifies the patient of all uses and disclosures of his or her protected health information. In addition, this form has a removable label that provides practices with a written acknowledgement that the patient received the Privacy Notice, as required to be HIPAA compliant.

Description

Quantity/Case

Price/Case

Secure Order

Notice of Privacy Practices in Spanish
(HIP120S)

250

$159.95

You can also order by Phone or Online:

CALL US
TOLL FREE AT:
1-877-840-1500
Our Office Hours ar
8-5 Mon.-Fri. CST

Order HIPAA
forms online

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HIPAA COMPLIANCE FORMS

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