Form Hipaa 702p - Disclosures Tracking Form - Louisiana Department Of Health

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Disclosures Tracking Form
Individual’s Name: (Last, First, MI)
Medicaid ID # or Social Security #:
Use this form for disclosures made without a signed authorization form. A copy of this form may be provided to
the individual requesting an accounting of disclosures made by your office.
Purpose of
PHI/Information
Date
Disclosure
Requestor’s Name,
Date
Disclosed
Disclosed
Request
(i.e .audit review, law
Address, Phone #
Disclosed
By
Received
enforcement, public
health, research)
Request for Accounting of Disclosures
Use this section to document accounting requests when a copy of this disclosure tracking form is provided to the
individual requesting the accounting.
Requested By
Date Range Requested
Request Completed By
Date & Method
Date Requested
Indiv/Per Rep
(After 4/13/03)
(Name & Title)
(mail, e-mail, fax)
HIPAA 702P
Page 1 of 1
Issued 4/14/03
Revised 09/17/2013

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