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