Get Request For An Accounting Of Disclosures - Uc Davis Health System ... - Ucdmc Ucdavis

This guide will provide you with step-by-step instructions on how to fill out the Request For An Accounting Of Disclosures form for the UC Davis Health System. Understanding the process is essential for ensuring your rights to access your medical information are upheld.

Follow the steps to complete your request effectively.

1. Click the ‘Get Form’ button to obtain the form and open it in the online editor.
2. Enter the date in the designated field to indicate when you are making the request.
3. Provide your full name in the specified section to identify the individual requesting the accounting of disclosures.
4. Fill in your date of birth to help verify your identity.
5. Input your medical record number in the appropriate field, as this is crucial for accessing your health information.
6. Select the time period for which you want the accounting of disclosures, ensuring it does not exceed six years and does not include dates before April 14, 2003.
7. Choose the preferred format for receiving the accounting of disclosures: on paper or electronically. Note that electronic delivery may not always be available.
8. If you choose to receive the accounting by mail, provide the full address or email address where you want it sent.
9. If you wish to pick up the accounting in person, indicate this and provide a contact phone number so they can notify you when it is ready.
10. Review all entered information for accuracy before signing the form at the bottom.
11. If applicable, include the relationship to the patient if a representative is signing, and ensure all fields are completed.
12. Save any changes made to the form, and utilize the options to download, print, or share the completed form as necessary.

Complete your request for an accounting of disclosures online today.