REQUEST FOR AN ACCOUNTING OF DISCLOSURES

REQUEST FOR AN ACCOUNTING OF DISCLOSURES
Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Social Security Number
Medical Record Number
Account Numbers
Address
Address To Send Disclosure Accounting If Different From Above
I would like an accounting of disclosures for the dates noted below:
From

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
To

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
(Note: The earliest date of disclosure information that can be provided is April 14, 2003, in accordance with the HIPAA Privacy Regulation 45 CFR 164.528)
There is no charge for the first accounting request. For subsequent requests within the 12 month period, the charge is
I understand that there is:
Signature of Patient or Legal Representative
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
THIS SECTION TO BE COMPLETED BY CAPE FEAR VALLEY HEALTH SYSTEM STAFF:
Date request received

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date accounting mailed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Extension Request
If yes, state reason for extension
Copy of notice mailed on

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Staff Signature
Facility Name
Should be Empty: