Request for Accounting of Disclosures of Protected Health Information

Request for Accounting of Disclosures of Protected Health Information
Request Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
- Patient Name
  
  First NameMiddle NameLast Name
- Date of Birth
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Patient Representative (Power of Attorney or Legal Guardian)
  
  First NameMiddle NameLast Name
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Phone Number
  Format: (000) 000-0000.
- Email Address
- By checking this field, I agree to the below terms:
- From:
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- To:
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- I understand that this Accounting of Disclosures will include all disclosures except:
  - to those for whom use and disclosure of my health information was made to carry out my treatment, process payment for my health care, or carry out Corstrata’s health care business operations
  - to myself or my personal representative
  - those that are incidental disclosures made in connection with a use or disclosure otherwise permitted or required by HIPAA
  - to persons involved in my care or as part of an inpatient directory
  - those pursuant to an authorization for release of information signed by myself or my personal representative
  - for national security or intelligence purposes, to correctional institutions, or to law enforcement officials under certain circumstances
  - to correctional institutions or law enforcement officials under certain circumstances
  - as part of a limited data set, when the recipient has executed a data use agreement, disclosed for research, public health, or certain health care operations purposes
- Send Accounting of Disclosures to:
  
  Fax (List #)
- Print Full Name
- Completed/Signed by:
- Signature
- Please attach a copy of your government-issued ID. If signed by Patient Representative, provide relationship to the patient and proof of Legal Representation
  
  Cancelof
- Corstrata, Inc.
  Privacy Officer
  P.O. Box 30643
  Savannah, GA 31410
  Phone #: (800) 566-1307
  Fax #: (855) 236-5024
  Email: Privacy@Corstrata.com
- Should be Empty: