Fill and Sign the Request Accounting Form

REQUEST FOR ACCOUNTING OF DISCLOSURES OF PROTECTED HEALTH INFORMATION I hereby request a written accounting of disclosures of protected health information made for the individual named below. D ATE :       PATIENT/RESIDENT/CLIENT L AST N AME :       F IRST N AME :       M IDDLE I NITIAL :       A DDRESS       C ITY /S TATE :       Z IP C ODE :       T ELEPHONE N UMBER :       SSN (O PTIONAL ):       D ATE OF B IRTH :       AKA’ S :       ACCOUNTING TIMEFRAME (DATE MAY NOT BE BEFORE APRIL 14, 2003) B EGINNING D ATE F OR W HICH A CCOUNTING IS R EQUESTED :       E NDING D ATE F OR W HICH A CCOUNTING IS R EQUESTED :       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 S IGNED BY L EGAL R EPRESENTATIVE , R ELATIONSHIP TO I NDIVIDUAL :       FOR _____________ USE ONLY Date Received: _________________________________________________________________ Date Accounting Sent: ___________________________________________________________ Extension Requested?  Yes  No If Yes, Reason: _______________________________ Date Individual Notified of Extension Request: _________________________________________ Request Processed by: ___________________________________________________________