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
Name and Address (if known) of Entity
Receiving Protected Health Information
Description of PHI
Statement of Purpose of
1/2015 © 2015 File in Member Record Retain indefinitely