Request Form For Accounting Of Disclosures Of Health Information
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1REQUEST for ACCOUNTING OF DISCLOSURES of HEALTH INFORMATION
Please print all requested information to prevent delays in our response & provide completed form to your facility.
Patient
Name:________________________________________________________________________________________________
Last
First
MI
Maiden or Other Name
ddress:___________________________________City:_______________________ST: _______Zip:_________
A
Date of Birth:____-____-_____
Phone #:_________________________________
I request an accounting for disclosures of my health information for the period: From:_
To:_________
I understand that this accounting for disclosures will include disclosures made only to those organizations or
persons other than:
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 operations;
to myself or persons involved in my care;
pursuant to my authorization;
for national security or intelligence purposes;
to correctional institutions or law enforcement officials under certain circumstance; or
those occurring prior to April 14, 2003
those exceeding a period of six years prior to the date of this request.
I understand that my request for an accounting of disclosures will be processed within 60 days of submitting this
form. I will be notified of the need for an extension of not more than 30 days to process the request, the reasons for the
delay and the date when I can expect to receive the requested accounting.
Please send this accounting by:
Paper Copy call at number above to pick up or mail to address above
or other electronic method ____________________________
* Email
*For security of your records, all emails are routinely sent encrypted.
Unencrypted email disclaimer: I understand that records sent through unencrypted email poses a security risk and
that is my requested method of receipt._
(Please initial)
OR
SIGNATURE OF INDIVIDUAL
DATE
SIGNATURE OF PERSONAL REPRESENTATIVE
DATE
RELATIONSHIP TO INDIVIDUAL
FOR INTERNAL USE ONLY
Complete the sections below and place in patient record.
Notice of Decision
Disclosure Handling: Completed
Denied
Disclosures occurred prior to April 14, 2003
If denied, reason for denial is:
Disclosure exceeds more than a six-year period
No disclosures made for reasons other than those permitted as listed above.
Staff member who processed request
Title
Phone
Date completed
Acct. Disc – ENG GCHJF57EN 08/15
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