REQUEST BY PERSON SERVED FOR ACCOUNTING OF DISCLOSURES You have a right to request an “accounting of disclosures” which is a list that provides information about certain ways we have disclosed your protected health information to persons or organizations outside of the agency. Please see our Notice of Privacy Practices for a more detailed description of your rights to request this accounting list and the process we follow once we have received your request. If you would like to request an accounting of disclosures after reading the information in our Notice of Privacy Practices, please complete and return the form below.
Name of person served: ________________________________________________________________ Last name First name MI Address: ____________________________________________________________________________ Phone: __________________________________ (day) _________________________________ (eve) E-mail address: _______________________________________________________________________
Request for accounting list: I would like an accounting of all disclosures made during the following period of time: From _____/_____/_____ to _____/_____/_____ Please note that we may not be able to include disclosures that were made before April 14, 2003 because we were not required to collect this disclosure information until after that date.
Possible fees: You are entitled to one free accounting list every 12 months. If you have already requested an accounting within the last 12 months, we may charge a reasonable feel to cover the costs of producing any additional lists you are requesting on this form. We will notify in before any fee is charged so that you may decide whether to continue with your request, modify your request to reduce the fee, or withdraw your request and pay no fee. Please send completed form to: Privacy Officer The Arc of Monroe County 1000 Elmwood Ave, Suite 500 Rochester, NY 14620
By signing below, I am requesting that The Arc of Monroe County provide me with the accounting list described above. I understand that I will be contacted if any fee will be charged for providing this accounting list and that I will have an opportunity to modify or withdraw my request if I do not want to pay those fees.
Accounting of disclosures forms
______________________________________________________ Printed name of person served or personal representative
________________________ Date
______________________________________________________ Signature of person served or personal representative
________________________ Date
______________________________________________________ Description of person representative’s authority
For The Arc of Monroe County use only Date received: _____/_____/_____ Date request was fulfilled/completed: _____/_____/_____ Fee charged for fulfilling this request (if any): $____________ Name of staff person processing this request: ____________________________________________
Accounting of disclosures forms
Sample letter providing notice of delay in response time for accounting request
[date]
[name of person served] [address] [city, state, zip]
Re: Request for accounting list
Dear [name]: This letter responds to your request for an accounting list which we received from you on _____________________. We have been working hard to produce the accounting list you have requested. We are usually able to provide these lists within 60 days. However, due to unusual difficulties retrieving the information for the list that you have requested, we need an additional 30 days to fulfill your request. We expect to have the list available for you no later than ____________________. Please contact the privacy officer if you have questions or concerns about this delay. You can call (585) 271-0660 to connect with him/her. Written questions or concerns can be sent to his/her attention at: The Arc of Monroe County, 1000 Elmwood Ave Suite 500, Rochester, NY 14620. Thank you. Sincerely,
[person sending letter]
Accounting of disclosures forms
Letter notifying of fee for accounting of disclosures
[date]
[name of person served] [address] [city, state, zip]
Re: Request for accounting list
Dear [name]: This letter responds to your request for an accounting list which we received from you on ____________________________. You are entitled to one free accounting list every 12 months. Our records indicate that you have already requested and received a free accounting list in the past 12 months. That list was provided on ________________. If you ask us to proceed with your current request for an additional accounting list, we will charge a fee of $________________ to recover the costs of providing the list. We want you to know that you have the following options: You may ask us to proceed with your request and pay the fee provided above You may modify your request for an accounting list and reduce the applicable fee You may withdraw your request and pay no fee.
Please contact the privacy officer via (585) 271-0660 to discuss your preferences for payment of applicable fees. You can also send your preference to his/her attention at: The Arc of Monroe County, 1000 Elmwood Ave Suite 500, Rochester, NY 14620. If we do not hear from you within 60 days, we will assume that you have decided to withdraw your request. If you have any questions, please feel free to contact the privacy officer. Thank you. Sincerely,
[person sending letter]
Accounting of disclosures forms
