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Accounting of Disclosures of Protected Health Information
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Patient Name: ________________________________ ID#
___________________Date:__________________
There are some situations in which [insert physician/organization name] is required or permitted by law to disclose your health information to persons outside of our office. In response to your request, we are providing you with this accounting of disclosures we have made of your information.
- We have made no disclosures of your health information that require an accounting.
- We have made the following disclosures:
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Recipient Name |
Recipient Address |
Description of PHI Disclosed |
Purpose of Disclosure |
Frequency of Disclosure/Date of Last Disclosure |
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This accounting does not include disclosures we have made to carry out treatment, payment or health care operations or disclosures you have specifically authorized. It also does not include any disclosures the law exempts from our accounting requirements.
If you have questions about this accounting, please contact [insert name and title of contact person] at [insert phone number].
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THIS DOCUMENT SHOULD BE CONSIDERED ONE EXAMPLE OF HOW AN ORGANIZATION
CAN START THEIR COMPLIANCE EFFORTS.
THIS DOCUMENT IS PROVIDED AS GENERAL GUIDANCE AND DOES
NOT CONSTITUTE LEGAL ADVICE.
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Return to MIEC HIPAA "Starter
Kit" |