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Accounting of Disclosures Request Form - Facey Medical Group

Accounting of Disclosures Request Form - Facey Medical Group

Accounting of Disclosures Request Form - Facey Medical

Accounting of Disclosures Request Form (For use by patients requesting an accounting of disclosures.) Patient Name: Address: Date of Request: Medical Record Number: Date of Birth: Telephone Number: You can ask for a list of disclosures of your Protected Health Information (PHI) made by the organization. If you would like this information, please consider the following: • The list is free one time in any twelve-month period. The organization will charge you for additional lists in the same twelve-month period. • The organization will not list disclosures made more than six years before your request. I am asking for a list of disclosures for the following period of time: (be specific) From: ____________________________ to: ______________________________ Reason for Request:_________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ Patient’s Signature Date Signed (See other side for information on patient rights) Approved ❏ Denied HIM Comments: ❏ Organization Representative Signature: Date: Revised 09/04/2012 1 SCAN under HIPAA*

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