Cameron University
Health Plan
Request for Accounting of Disclosures — Health Plan
Date of Birth: Member Name:
Member: ID#:
Address where you would like the Accounting sent:
Street City State Zip
NOTICE TO MEMBER:
Your request for an Accounting of Disclosures of your protected health information is applicable only to the information maintained
by Cameron University Health Plan. If you would like to request an Accounting of Disclosures of your protected health information
from any other University entity, a separate request must be submitted to that University entity. (This request is applicable only to
records disclosed by the Cameron University Health Plan.)
REQUEST FOR ACCOUNTING OF DISCLOSURES:
I request an Accounting of Disclosures of the protected health information in my designated record set covering the
period from to (not to exceed 6 years, nor be for disclosures prior to April 14, 2003)
maintained or created by the Health Plan.
I understand that the first Accounting in a 12-month period is free of charge, but I can be charged a reasonable fee for any
additional accountings during that period. I will be notified of any charge in advance.
I understand that the Accounting must include all disclosures, except for disclosures
1. t
o carry out treatment, payment, or health care operations
;
2. of my own protected health information to me;
3. inc
ident to a use or disclosure permitted by the HIPAA Privacy regulations
;
4. p
ursuant to my Authorization
;
5. t
o persons involved in my care
;
6. for national security or intelligence purposes;
7. t
o correctional institutions or law enforcement officials to provide them with the information about a person in the
ir
c
ustody
;
8. a
s part of a limited data set; o
r
9. t
hat occurred prior to April 14, 200
3
Title, if legal representative*
*May be requested to show proof of representative status.
File in Member Record HIPAA Document
Rev. 1/2-015 Retain for a minimum of 6 years
© 2015
