REQUEST FOR AN ACCOUNTING OF DISCLOSURES

REQUEST FOR AN ACCOUNTING OF DISCLOSURES
Name*
Date of Birth*

MonthDayYear
Date
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
Date
To*

MonthDayYear
Date
(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:*

No fee for this requestA fee for this request in the amount specified above and I wish to proceed
Signature of Patient or Legal Representative*

Clear
Date*

MonthDayYear
Date
THIS SECTION TO BE COMPLETED BY CAPE FEAR VALLEY HEALTH SYSTEM STAFF:
Date request received

MonthDayYear
Date
Date accounting mailed

MonthDayYear
Date
Extension Request

YesNo
If yes, state reason for extension
Copy of notice mailed on

MonthDayYear
Date
Staff Signature

Clear
Facility Name
Should be Empty: