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Request for Accounting of PHI Disclosed by Williams College I request an accounting of all PHI disclosed by Williams College's (fill in name of department or
 

Summary: Request for Accounting of PHI Disclosed by Williams College
I request an accounting of all PHI disclosed by Williams College's (fill in name of department or
office) _______________________________________________ pursuant to the requirements of the
HIPAA Privacy Rule. I understand that this accounting will not include disclosures that were:
1. made prior to April 14, 2003;
2. made to carry out my treatment, payment for my treatment, or operational activities;
3. made to me or my personal representative;
4. made pursuant to an authorization from my personal representative or me;
5. made incident to a use or disclosure that is otherwise permitted to be made by Williams
College;
6. made to discuss my healthcare with a family member or other individual involved in my
care, or for other notification purposes permitted by law;
7. made as part of a limited data set (a medical record that includes PHI that could be used
to identify me, but is redacted of obvious identifying information);
8. made for national security and intelligence purposes; or
9. made to a correctional institution or to law enforcement when I was an inmate or
otherwise in custody at the time of disclosure.
The period of time I am requesting the accounting for is from:
______________________________ to _______________________________
I understand that this period of time can be for no longer than 6 years and cannot include any time

  

Source: Aalberts, Daniel P. - Department of Physics, Williams College

 

Collections: Physics