Get Request For An Accounting Of Disclosures Of Protected Health Information By Parent, Guardian Or

This guide provides clear instructions for completing the Request For An Accounting Of Disclosures Of Protected Health Information by a parent, guardian, or legal representative. Follow these steps to ensure a smooth and accurate submission of your request.

Follow the steps to successfully fill out the form online.

1. Click ‘Get Form’ button to access the Request For An Accounting Of Disclosures Of Protected Health Information form and open it in your preferred editing environment.
2. Fill in the client information section, including the last name, first name, address, city/state, client index number, date of birth, middle initial, zip code, and date of death if applicable.
3. Complete the parent, guardian, or legal representative information with your last name, first name, address, city/state, middle initial, and zip code.
4. Provide your contact details, including daytime and evening phone numbers, email address, and best hours to reach you.
5. Indicate your legal authority to request an accounting of disclosures by selecting the appropriate option (parent, conservator, guardian, executor of will, medical power of attorney, or other). Attach any necessary legal documentation supporting your claim.
6. Attach a copy of your identification, indicating the type (CA driver’s license, CA DMV identification card, etc.) and the identification number.
7. Specify the date range for which you are requesting the disclosure accounting by filling in the 'from' and 'to' month/year fields.
8. Declare the truthfulness of the provided information by signing and dating the form. If no identification is provided, ensure your signature is notarized.
9. Attach proof of address verification, indicating the type of document (utility bill, phone bill, etc.).
10. Once you have completed all fields and attached required documents, save your changes, and prepare to submit the form as instructed.

Complete your documents online to ensure a successful request for an accounting of disclosures.