ACCOUNTING FOR DISCLOSURES FORM
There were no applicable disclosures made of your protected health information for the period you specified.
Disclosures of your protected health information were made by this office to:
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Date of Disclosure |
Name of Whom Information Was Disclosed |
Address |
Description of Information Disclosed |
Purpose of Information Disclosed |
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We are temporarily unable to process the accounting for disclosures you have requested due to:
A suspension required by law.
Other, specify:
However, your request will be provided by
(Month/Day/Year)
If you have any questions concerning this accounting for disclosures, please contact:
Signature