The Coalition of Behavioral Health Agencies, Inc.: HIPAA

The Coalition - HIPAA Training Tools Order Form

Please print this order form and mail completed form along with a check to:

The Coalition of Behavioral Health Agencies
Attn: Patricia Gallo Goldstein
90 Broad Street, 8th Floor
New York, NY 10004



HIPAA Toolkit               __ $230.00 Member  __ $305.00 Non-member

HIPAA Privacy Rule Video    __ $ 54.95 Member  __ $104.95 Non-member

HIPAA Privacy Officer Video __ $ 54.95 Member  __ $104.95 Non-member

Complete HIPAA Series       __ $306.00 Member  __ $481.00 Non-member

Total Enclosed $_____


Organization Name: ____________________________________

HIPAA Compliance Officer: _____________________________

Phone Number: _________________________________________

Email Address: ________________________________________

Ship to: ______________________________________________

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If you have any questions, please contact Patricia Gallo Goldstein at patgg@coalitionny.org or 212-742-1600 ext 106
or Karyn Krampitz at kkrampitz@coalitionny.org or 212-742-1600 ext 210.