Fill and Sign the Form 400 Lease

Accounting of Disclosures Request Form You have the right to receive an accounting of many of the disclosures made by Mutual of Omaha of your protected health information (medical information). Please provide the following information about the person whose records are being requested so that we can process your request. Name: ___________________________________________ Address: _________________________________________ _________________________________________ City: ____________________ State: ______ Zip: ________ - _______ Home Telephone Number: ( ) ____________________ Policy/Group Number: _____________________________ If this coverage is provided through an employer, provide the Subscriber Number: _______________________________ Period of time for which you wish to see the disclosures made by Mutual of Omaha. Note that you can request a list of disclosures for any time period after April 14, 2003. _______________________ to ______________________ This accounting information will be sent to the above address via first class mail. Unless your state has different requirements, we are not required by federal law to include any of the following disclosures of your protected health information in an accounting to you: ■ ■ ■ ■ ■ ■ ■ Disclosures to carry out treatment, payment and health care operations; Disclosures made to you or your personal representative; Disclosures made to persons involved in your care or notification of next-of-kin or family members; Disclosures for national security or intelligence purposes; Disclosures to correctional institutions or law enforcement officials about inmates or others in custody; Disclosures made pursuant to your authorization; or Disclosures that occurred prior to April 14, 2003. If you request more than one accounting in any 12-month period, we may charge you for each subsequent accounting requested. Print Name: ______________________________________ Relationship: _____________________________________ Signature: _______________________________________ Date: ____________________________________________ Note that no accounting request will be processed unless you or your authorized representative have signed this form. If you are an authorized representative (other than a parent of a minor child), you will need to provide documentation or an explanation of your authority to act for the customer (e.g., Power of Attorney). Please return completed form and any additional attachments to Mutual of Omaha at: Mutual of Omaha Attn: Privacy Office Mutual of Omaha Plaza Omaha, NE 68175-1029 MC31519_0305