Request For Accounting Of Disclosures For Health Information
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1SSMHC Request for Accounting of Disclosures for Health Information
I, ____________________________, request an accounting of disclosures of my health information for the period:
(Print Name)
FROM:_______________________________________TO:________________________________________
FOR THE PURPOSE OF:____________________________________________________________
The patient or patient’s representative must read and initial where indicated.
I understand that this accounting will include known disclosures made only to organizations or persons other than:
Initials___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 health care operations to myself or persons involved in my care
or where I signed an authorization for release of information
Initials___for national security or intelligence purposes, to correctional institutions, or to law enforcement officials under
certain circumstances (as specified in your Notice of Privacy Practices)
Initials___ that occurred prior to six (6) years from this date of request.
Initials___ I understand that I may receive the first accounting of disclosures within a 12-month period at no charge.
Initials___ I understand that I am requesting a second or subsequent accounting in a 12-month period and will pay a
charge for this accounting.
PATIENT NAME:_____________________________________________ __________________________________ _______
LAST
FIRST
MI
DATE OF BIRTH:____-____-____ FORMER NAME:_______________________MEDICAL RECORD #________________
MO DAY YR
ADDRESS:_____________________________________________ CITY:__________________________STATE:____ZIP:_____________
DAY PHONE:__________________________EVENING PHONE:____________________________
Patient/Legal Representative
Signature:
__________________________________DATE: ______________ RELATIONSHIP: ______________________
Send accounting to my mailing address above.
Send accounting to my e-mail Address:__________________________________________________
Accounting of Disclosures
There were no disclosures known to us; which require accounting of your health information for the period you specified.
As of this date: ______________________________ disclosures of your health information were made to:
Date of Accounting
Date of Disclosure
Name and Address to whom disclosed
Description of information disclosed
Purpose of disclosure
We are temporarily unable to process the accounting for disclosures you have requested due to:
a suspension required by law
other: ___________________________but will comply with your request by the date of:________________
If you have any questions concerning this accounting of disclosures, please contact our Information Privacy
Official, [supply site name, address, and phone number and/or e-mail/web site]
FOR OFFICE USE ONLY:
LAST
PAID
1406163v3 - P20 v1.3 Patient Rights to an Accounting of Disclosures - Page 1 of 1
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