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| Form Title: | HIPAA Request for Disclosure Accounting Form |
| Last Revised: | 4/2003 |
| Purpose: | As required by the Health Information Portability and Accountability Act of 1996 (HIPAA) you have a right to request an accounting of disclosures of health information that pertains to you. |
| Who Should Use the Form: | Employee |
| Instructions: | The employee completes the Request for Disclosure Accounting Form, signs and submits to Laurie Carr (confidential internal mail to CG4 or fax 303-497-8701). |
| View the Form: | Click Here to View a Blank Form in .pdf Format |
| Form Download Information | |
| File Format: | Excel 5.0 (.xls) |
| Download File: | Click Here to Download the Form! |
| Problems? Contact: | Laurie Carr, x8702 |
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