HIPAA Forms

Health Insurance Portability & Accountability Act

  1. Authorization to Use and Disclose Specific Protected Health Information (PDF)
  2. HIPAA-Authorization to Release PHI
  3. List of Designated Privacy Officials (PDF)
  4. Notice of Privacy Practices
  5. Patient Request for Restriction Form (PDF)
  6. Procedure for Filing Complaints About Privacy Practices (PDF)
  7. Request for Amendment of Protected Health Information (PDF)
Emergency Medical Services responders care for injured individual on stretcher

Contact Us

  1. dkfd iso2 logo - square

    Mike Thomas

    Fire Chief


    DeKalb Fire Department


    700 Pine Street
    DeKalb, IL 60115

    Phone: 
     815-748-8460