The University of Oklahoma Health Plan Request for Accounting of Disclosures Health Plan — Member Name: _______________________________ Date of Birth: ___________________ 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 the University of Oklahoma 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 OU 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 to carry out treatment, payment, or health care operations; of my own protected health information to me; incident to a use or disclosure permitted by the HIPAA Privacy regulations; pursuant to my Authorization; to persons involved in my care; for national security or intelligence purposes; to correctional institutions or law enforcement officials to provide them with the information about a person in their custody; as part of a limited data set; or that occurred prior to April 14, 2003 Signature Title, if legal representative* Date *May be requested to show proof of representative status.
The University of Oklahoma Health Plan Request for Accounting of Disclosures — Health Plan Member Name: _______________________________ Date of Birth: ___________________ 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 the University of Oklahoma 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 OU 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 to carry out treatment, payment, or health care operations; of my own protected health information to me; incident to a use or disclosure permitted by the HIPAA Privacy regulations; pursuant to my Authorization; to persons involved in my care; for national security or intelligence purposes; to correctional institutions or law enforcement officials to provide them with the information about a person in their custody; as part of a limited data set; or that occurred prior to April 14, 2003 Signature Title, if legal representative* Date *May be requested to show proof of representative status.