Individual Name: __________________________________ Individual Number: ____________________ Date Person Date of Name and Address of Description of PHI Purpose of Disclosure (or Name of request making Disclosure Recipient of PHI disclosed copy of written request) Staff received request processing request
Individual Name: __________________________________ Individual Number: ____________________ Date request received Person making request Date of Disclosure Name and Address of Recipient of PHI Description of PHI disclosed Purpose of Disclosure (or copy of written request) Name of Staff processing request
Iowa-Counties-and-Regions-HIPAA-Privacy-and-Security-Policies-Template-For-Counties-not-ISAC-2.docx