REQUEST for ACCOUNTING OF DISCLOSURES of HEALTH INFORMATION
Please print all requested information to prevent delays in our response & provide completed form to your facility.
Maiden or Other Name
Date of Birth:____-____-_____
I request an accounting for disclosures of my health information for the period: From:_
I understand that this accounting for disclosures will include disclosures made only to those organizations or
persons other than:
to those for whom use and disclosure of my health information was made to carry out my treatment,
process payment for my health care, or carry out your operations;
to myself or persons involved in my care;
pursuant to my authorization;
for national security or intelligence purposes;
to correctional institutions or law enforcement officials under certain circumstance; or
those occurring prior to April 14, 2003
those exceeding a period of six years prior to the date of this request.
I understand that my request for an accounting of disclosures will be processed within 60 days of submitting this
form. I will be notified of the need for an extension of not more than 30 days to process the request, the reasons for the
delay and the date when I can expect to receive the requested accounting.
Please send this accounting by:
Paper Copy call at number above to pick up or mail to address above
or other electronic method ____________________________
*For security of your records, all emails are routinely sent encrypted.
Unencrypted email disclaimer: I understand that records sent through unencrypted email poses a security risk and
that is my requested method of receipt._
SIGNATURE OF INDIVIDUAL
SIGNATURE OF PERSONAL REPRESENTATIVE
RELATIONSHIP TO INDIVIDUAL
FOR INTERNAL USE ONLY
Complete the sections below and place in patient record.
Notice of Decision
Disclosure Handling: Completed
Disclosures occurred prior to April 14, 2003
If denied, reason for denial is:
Disclosure exceeds more than a six-year period
No disclosures made for reasons other than those permitted as listed above.
Staff member who processed request
Acct. Disc – ENG GCHJF57EN 08/15