In order to complete your request, you must complete the form and send it via email to moc.r1660347373psula1660347373s@MIH1660347373 or by fax to 787-789-2180. If you have any questions or concerns, please call 787-789-1996.

Forms
Size
File

Request for inspection or access to personal health information

This form is used for a patient to request to inspect or obtain a copy of his/her information in a designated record set that we maintain or that our business associates maintain for us.

60 KB

Authorization to Disclose Protected Health Information

Form to authorize Salus to disclose protected health information.

59 KB

Personal Representative Appointment

This form will be used for patients to appoint the persons who will represent them in various processes with Salus.

24 KB

Revocation of Authorization Form

This form is used for revoking or confirming the revocation of a previously granted authorization.

51 KB

Confidential Communication Request Form

This form is used for documenting an individual's request to use alternative channels or addresses to send their information.

30 KB

Disclosure Report Request Form

This form is for requesting a report on protected health information disclosures.

49 KB

Request for Restriction on the Use or Disclosure of Information

This form is used to request a restriction on the use or disclosure of information pertaining the individual requesting the restriction.

41 KB

Amendment Request Form

This form serves to document the request to amend the information kept by us or by our business partners

18 KB

Grievance Form

This form will be used by individuals to file their grievances regarding our compliance with privacy practices.

50 KB

Non-urgent Medical Treatments

Consent by Proxy Form for the non-urgent medical treatment of minors

81 KB

Advance Directives

They help us tell our relatives what kind of healthcare we wish to receive.

77 KB