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Health Information Privacy

HHS Privacy Policy

OCR Speaker Request - Health Information Privacy

Thank you for your interest in OCR's health information privacy program. Please submit this completed form that will help us evaluate your request. For more information, contact OCR at OCRPrivacy@hhs.gov.

Registration

Sponsor Information:

Sponsoring Organization:

Point of Contact Name:

Title:

Phone #:

Ext:

Fax:

Email:

Event Information:

Event:

Date:

MM/DD/YYYY

City:

State:

Venue:

Event Website URL:

Type of Event:

Type of Audience:

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Mac: Command + Click to select multiple items

Number of Attendees:

Requested OCR Presentation:

Type:

Topic:

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Mac: Command + Click to select multiple items

Length of Time:

OCR Speaker, if known:

Requested Materials:

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Type of Audio/Video and IT Provided:

Is the event open to the public?

Yes No

Is there a cost to attend?

Yes No Cost $

Is there a cost for the OCR Presenter?

Yes No Cost $

What is the cost for federal government attendees?

Cost $

Date response requested by:

MM/DD/YYYY

Please indicate any additional information:

Attachment(s):

Accepted File Types: .doc, .docx, .pdf, .jpg, .jpeg, .gif (Maximum File Size: 200KB per file)
NOTE: Only file(s) of type and max size indicated above will be accepted. Everything else will be ignored.

Maximum allowed number of files for this request has been reached.