Fill and Sign the I Hereby Request a Written Accounting of Disclosures of Protected Health Information Made for

REQUEST FOR ACCOUNTING OF DISCLOSURES OF PROTECTED HEALTH INFORMATION I hereby request a written accounting of disclosures of protected health information made fo r the individual named below. D ATE : PATIENT/RESIDENT/CLIENT L AST NAME : F IRST NAME : M IDDLE INITIAL :      A DDRESS C ITY /STATE : Z IP CODE : T ELEPHONE NUMBER : SSN (O PTIONAL ): D ATE OF BIRTH : AKA’ S: ACCOUNTING TIMEFRAME (DATE MAY NOT BE BEFORE APRIL 14, 2003) B EGINNING DATE FOR WHICH ACCOUNTING IS R EQUESTED : E NDING DATE FOR WHICH ACCOUNTING IS REQUESTED : DISCLOSURES EXCLUDED FROM ACCOUNTING REQUIREMENTS I understand that not all disclosures or protected health information must be included in the accounting. Federal regulations DO NOT require the following disclosures to be included in the accounting:  Disclosures made for treatment, payment, and healthcare operations;  Disclosures made to me;  Disclosures authorized by me;  Disclosures made for the facility’s patient directory;  Disclosures made to persons involved in my care;  Disclosures made for national security or intelligence purposes;  Disclosures to correctional institutions or law enforcement officials for individuals who were imprisoned or in police custody;  Disclosures made prior to April 14, 2003;  Disclosures that are part of a limited data set; and  Disclosures that do not identify individuals. TIME PERIOD FOR RESPONSE I understand that federal regulations require _____________ to respond to my request within 60 days of receipt. _____________ may extend that time period by 30 days if I am notified of this in writing. FEES I understand that the first accounting in a 12-month period will be provided free of charge. If I request additional accountings in the same 12-month period, I will be charged a reasonable fee based on the cost of preparing the accounting. TEMPORARY SUSPENSION OF ACCOUNTING RIGHTS I understand that _____________ may temporarily suspend my right to receive an accounting of disclosures to a health oversight agency or law enforcement official if the health oversight agency or law enforcement official makes such a request in writing. If this is the case, I will be notified of this suspension and the time period for which the suspension is in effect. SIGNATURE OF INDIVIDUAL OR LEGAL REPRESENTATIVE S IGNATURE : D ATE : I F SIGNED BY LEGAL REPRESENTATIVE , R ELATIONSHIP TO INDIVIDUAL : FOR _____________ USE ONLY Date Received: _________________________________________________________________ Date Accounting Sent: ___________________________________________________________ Extension Requested?  Yes  No If Yes, Reason: _______________________________ Date Individual Notified of Extension Request: _________________________________________ Request Processed by: ___________________________________________________________