Individual Request For Accounting Of Certain Disclosures Of Protected Health Information For Non-Treatment, Payment, Or Healthcare Operations Purposes Made By Arkansas Blue Cross And Blue Shield

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Individual Request for Accounting
of Certain Disclosures of Protected Health Information for Non-Treatment,
Payment, or Healthcare Operations Purposes Made by
Arkansas Blue Cross and Blue Shield
As a member, you have the right to receive an accounting of certain non-routine disclosures of
your identifiable health information made by Arkansas Blue Cross and Blue Shield for non-
Treatment, Payment, or Healthcare Operations (TPO) purposes.
Your request must state a time period that may not be longer than six (6) years and may not
include dates before April 14, 2003.
The first list you request within a 12-month period will be provided free of charge. For
additional lists during the same 12-month period, you may be charged for the costs of providing
the list; however we will notify you of the cost involved and you may choose to withdraw or
modify your request.
To request an accounting of disclosures for non-TPO purposes made by Arkansas Blue Cross
and Blue Shield, you must submit your request in writing to the Arkansas Blue Cross Privacy
office.
Please inform me of where my protected health information (PHI) has been sent for purposes
other than treatment, payment and health care operations.
Name: ____________________________________________________________________
Address: __________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Phone Number: _____________________________________________________________
Member Identification Number: _________________________________________________
Do you participate in the Federal Employees Program? ______________________________
Signature: __________________________________________________________________
The request for an accounting of disclosures will be responded to within 60 days of the receipt of
the request, unless a 30-day extension is requested by us. After the first accounting request each
year, there will be a fee for additional accounting requests.
Please mail request to:
Arkansas Blue Cross and Blue Shield Privacy Office
P. O. Box 3216
Little Rock, AR 72203

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