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This document is a request for patients to receive an accounting of certain non-routine disclosures of their protected health information made by Texas Tech University Health Sciences Center, in compliance

How to fill out request for an accounting

How to fill out Request for an Accounting of Certain Disclosures of Protected Health Information

1. Obtain the Request for an Accounting of Certain Disclosures form from your healthcare provider or their website.
2. Fill in your personal information, including your name, address, and contact details.
3. Specify the time period for which you are requesting an accounting of disclosures.
4. Indicate the format in which you would prefer to receive the information (e.g., paper copy or electronic format).
5. List any specific types of disclosures you are particularly interested in, if applicable.
6. Sign and date the form to validate your request.
7. Submit the completed form according to the instructions provided (e.g., by mail, fax, or email).

Who needs Request for an Accounting of Certain Disclosures of Protected Health Information?

1. Patients who want to understand how their protected health information has been shared.
2. Individuals who have concerns regarding the privacy of their health information.
3. Patients who need to verify the disclosures made by their healthcare providers for legal or personal reasons.

People Also Ask about

What are disclosure requirements in accounting?

Any change in an accounting policy which has a significant effect should be disclosed. The amount by which any item in the financial statements is affected by such change should also be disclosed to the extent it can be calculated. Where such amount is not ascertainable, wholly or in part, the fact should be disclosed.

What is the law for accounting of disclosures?

Individuals have a right to receive, upon request, an accounting of disclosures of protected health information made by a covered entity (or its business associate), with certain exceptions.

What information must be included in the accounting of disclosure?

The Accounting for Disclosures Log and Response forms may provide the name of the protocol or other research activity, a description of the research protocol or activity (including the purpose of the research and the criteria for selecting particular records), a description of the type of PHI disclosed, the date or

Do patients have the right to request an accounting of disclosure?

Individuals have a right to receive, upon request, an accounting of disclosures of protected health information made by a covered entity (or its business associate), with certain exceptions.

What is an accounting of disclosures of PHI?

An “accounting” is a log of certain disclosures of full PHI that must be made available to a patient upon request that includes information about the disclosure like the date it occurred, the name of the recipient, a description of the PHI and the purpose.

When an individual makes a request for an accounting of disclosures what must the accounting for each disclosure include?

(1) Except as otherwise provided by paragraph (a) of this section, the accounting must include disclosures of protected health information that occurred during the six years (or such shorter time period at the request of the individual as provided in paragraph (a)(3) of this section) prior to the date of the request

How to request an accounting of disclosures?

Patients (or their Personal Representatives – see Yale Policy 5038 - Personal Representatives) may request an accounting of disclosures by submitting a request in writing using the Request for Accounting of Disclosures of Protected Health Information form, or other sufficient written documentation requesting the

For pdfFiller’s FAQs

What is Request for an Accounting of Certain Disclosures of Protected Health Information?

It is a formal request by individuals to obtain a record of certain disclosures made by a healthcare provider regarding their protected health information (PHI), as mandated by the Health Insurance Portability and Accountability Act (HIPAA).

Who is required to file Request for an Accounting of Certain Disclosures of Protected Health Information?

Any individual (or their authorized representative) who has received care and has their protected health information disclosed by a covered entity is entitled to file this request.

How to fill out Request for an Accounting of Certain Disclosures of Protected Health Information?

Individuals must complete a request form provided by the healthcare provider or entity, specifying details such as the timeframe of the disclosures sought and the type of information requested.

What is the purpose of Request for an Accounting of Certain Disclosures of Protected Health Information?

The purpose is to allow individuals to understand how their health information has been used and shared, and to promote transparency and accountability among health care providers.

What information must be reported on Request for an Accounting of Certain Disclosures of Protected Health Information?

The request must report details like the dates of disclosure, the recipient of the information, the purpose of the disclosure, and a description of the information disclosed.