Patient Request For An Accounting Of Disclosures Form printable pdf download

Patient Request For An Accounting Of Disclosures Form

Patient Request for an Accounting of Disclosures

The Health Insurance Portability and Accountability Act (“HIPAA”) gives you the right to receive an

accounting of certain disclosures of your health information that are made by NYU Langone Medical Center

(“Medical Center”) and its Business Associates for up to six (6) years prior to the date of your request. You

are not entitled to receive an accounting of disclosures that are made to carry out treatment, to obtain or

make payment for treatment, or for health care operations. You are not entitled to receive an accounting of

disclosures that are made to you or pursuant to your authorization, to your family or other persons involved

in your care, for national security, or certain law enforcement purposes.

You are entitled to one free accounting every 12 months. If you have already requested an accounting within

the last 12 months, we will charge you a reasonable fee of $50 to cover the costs of producing an additional

accounting. You will receive the accounting via certified mail within 60 days of receipt of your request.

To request an accounting of disclosures, please complete the form below and send to: Privacy Officer, NYU

Langone Medical Center, One Park Avenue, 3

Floor, New York, NY 10016.

I request an accounting of disclosures of my health information that were made during the following

time frame: from ____/____/______ to ____/____/______. I understand that I will be charged a

reasonable fee of $50 if I have already received an accounting within the last 12 months and I agree to

pay the fee.

Please send the accounting of disclosures to this address________________________________________

_______________________________________________________________________________________

Signature: _______________________________________ Date: __________ Time: _________ AM/PM

(Patient or person authorized to sign)

If the consenting party is other than the patient, print name and relation to patient:

_______________________________________________________________________________________

Office Use: Received: ____/_____/_____

Completed: ____/_____/_____ Initials: _______________

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(Rev. 11/13)

Patient Request For An Accounting Of Disclosures Form