Fillable Accounting of Disclosures Log (Cameron University)

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Accounting of Disclosures Log (Cameron University)

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Cameron University
Health Plan
Accounting of Disclosures Log
Notice: Check with Legal Counsel (405-271-2033) or the Privacy Official (405-271-2033) prior to
making any non-routine disclosures.
Date of Birth:
Member Name:
Member ID #:
Date of
Disclosure
Name and Address (if known) of Entity
Receiving Protected Health Information
(PHI)
Description of PHI
Disclosed
Statement of Purpose of
Disclosure
1/2015 © 2015 File in Member Record Retain indefinitely
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Accounting of Disclosures Log (Cameron University)

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Completed 22 July 2020

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