Medical Forms, Health Insurance Claim Forms, CMS1500, UB92, Hospital Claim Forms

HIPAA-For Accounting of Disclosures

HIPAA-For Accounting of Disclosures

HIPAA-For Accounting of Disclosures:

The patient who requests an "Accounting of Disclosures" will be asked to complete this form that requires the patient to provide the purpose of the requests, the dates requested, etc. The form, retained in the patient's medical record, also allows you to record the date you comply with the requests.

Format:
8.5" x 11", 1 Part with black ink- Blue "Void" security background. 5 hole punch left and 2 top for insertion in charts. Packaged in 100'S


View Sample
JPEG		HIPAA-For Accounting of Disclosures

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