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

This guide provides comprehensive instructions on how to fill out the REQUEST FOR AN ACCOUNTING OF DISCLOSURES OF PROTECTED HEALTH INFORMATION form online. By following the steps outlined below, users can easily navigate the process, ensuring all necessary information is submitted accurately.

Follow the steps to successfully complete the form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Fill out the client information section with the details of the individual for whom you are requesting the accounting of disclosures. This includes their last name, first name, address, city/state, BIC number, date of birth, middle initial, zip code, and date of death if applicable. Make sure to double-check that all information is accurate.
3. Continue by providing your own details as the parent, guardian, or legal representative. Complete the sections for last name, first name, address, city/state, daytime and evening telephone numbers, email address, and best hours to reach you.
4. Indicate your legal authority to request this accounting by checking the appropriate box (parent, conservator, guardian, executor of will, medical power of attorney, or other). Ensure to attach any necessary legal documentation that verifies your right to make this request.
5. Attach a photocopy of your identification. Specify the type of identification (e.g., California driver’s license, DMV identification card, employee ID card) and provide the identification number.
6. Clearly state the dates for which you are requesting the accounting of disclosures by filling in the corresponding fields for the start and end months and years.
7. Finally, sign and date the form to certify that the information provided is true and accurate. If you do not attach identification, your signature must be notarized.
8. After completing all sections, save changes to your form, and prepare to print, download, or share it as necessary. Ensure that all required documents are included before submission.

Complete your documents online today for a seamless submission experience.