Request For An Accounting Of Disclosures Of Medical Information

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The Children’s Hospital of Philadelphia
Request for an Accounting of Disclosure(s) of Medical Information
I, ______________________, request an accounting of disclosures of medical information of
____________________, excluding disclosures that are authorized, or disclosures made for
treatment, payment, or healthcare operations.
(PLEASE PRINT)
Patient Name:
__________________________________________ Date of Birth:_________________________
Address:
_______________________________________________________________________________
_______________________________________________________________________________
Phone Number(s):
_______________________________________________________________________________
Please list the time period for which you would like an accounting (THIS TIME PERIOD MAY NOT BE
MORE THAN SIX YEARS AND CANNOT INCLUDE DATES PRIOR TO APRIL 14, 2003):
________________________________
You will receive a response to your request in writing within sixty (60) days.
If The Children’s Hospital of Philadelphia is unable to give you with an accounting within sixty (60) days of
your request, you will receive a statement within those sixty (60) days informing you when you will be given the
accounting. In any case, the accounting will be provided to you within no more than ninety (90) days of the
receipt by The Children’s Hospital of Philadelphia of your original request.
The Children’s Hospital of Philadelphia may temporarily hold a patient's right to receive an accounting of
disclosures of her/his medical information as outlined in the Notice of Privacy Practices to a health oversight
agency or law enforcement agency if the accounting would be reasonably likely to make the agency's activities
more difficult.
DATE: _______________________
Signature of patient/parent/legal
guardian:____________________________________________________________________
Received by:_______________________________________________________________________________________
Title:______________________________________________________________________________________________
(TO BE COMPLETED BY CHILDREN’S HOSPITAL STAFF)
PATIENT MR#:_________________________________________
The Children’s Hospital of Philadelphia
Health Information Management Department
34th and Civic Center Boulevard
Philadelphia, PA 19104
.

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