Model

Patient Request for Accounting for Disclosures

of Health Information

I, , request an accounting for

(Print First and Last Name of patient/recipient)

disclosures of my protected health information for the period:

to

(Month/Day/Year) (Month/Day/Year)

I understand that this accounting for disclosures will not include:

• Disclosures to any entity regarding my treatment, payment, or health care operations

• Disclosure to me or my personal representative

• Disclosures that I authorized by completing an authorization form

• Disclosures Incident to a use or disclosure otherwise permitted or required by law

• Disclosures for national security or intelligence purposes (as specified in the Notice of Privacy Practices)

• Disclosures to correctional institutions or law enforcement officials under certain circumstances

I may receive the first accounting for disclosures within a 12-month period at no charge. If I am requesting a subsequent accounting within a 12-month period of another request, I will pay the charge of ($ Psychologist may impose a reasonable cost-based fee) for this accounting.

I may receive an accounting of disclosures for a period of up to 6 years from the date of this request for disclosures that occurred after April 14, 2003.

A response to your request for the accounting of disclosures must be made within a 60 day time period. This period may be extended for another 30 days if you are provided with a written statement of the reasons for the delay and the date by which you will receive the accounting. There are also certain circumstances where your right to receive an accounting for disclosures of your health information may be temporarily suspended.

Send this accounting to:

Name

Address

City State Zip

Patient/recipient Signature Date