Author: Kevin Dorsey-Tyler

SacValley

The Health Information Exchange
for California’s North Central Valley

MedShare

P.O. Box 9217
Chico, CA 95927-9217

Request for Accounting of Disclosures

Date: ______________ Date of Birth: ______________ MR#: ______________
Patient Name: _______________________________________________________
I would like an accounting of how my protected health information was disclosed by SacValley MedShare, as required by federal regulations. I understand that the HIE does not have to tell me about the following types of disclosures:
Disclosures for purposes of treatment, payment, and healthcare operations or as part of a limited data set.
Disclosures to me or disclosures authorized by me.
Disclosures for use in the HIE’s directory.
Disclosures to persons involved in my care.
For notification purposes (to notify a family member, personal representative, or other person of my location, general condition, or death).
For national security or intelligence purposes.
To correctional institutions or law enforcement officials.
Disclosures made prior to: _____________
Disclosures incident to a use or disclosure otherwise permitted or required by
federal law.
I also understand that my right to an accounting of some or all disclosures may be suspended by the government under limited circumstances.
I want an accounting of disclosures that covers the following time period:
______________________________________________________________
NOTE: The time period must be no longer than 6 (six) years.
Please scan and email to: info@sacvalleymedshare.org –OR-
Mail to: SacValley MedShare, 1448 Esplanade, Chico CA 95926
This request can take up to 60 (sixty) days to be completed.

SVMS-FORM-016.002 Request for an Accounting of Disclosures - English Page 1 of 3

SacValley

The Health Information Exchange
for California’s North Central Valley

MedShare

P.O. Box 9217
Chico, CA 95927-9217

Request for Accounting of Disclosures

I want the accounting of disclosures in the following form: r On Paper
r I want the accounting mailed to me. Please mail to the following address:
___________________________________________________________
Address City State Zip
r Electronically
r Please e-mail my accounting to the following address:
________________________@________________________________
E-mail Address
I understand that the HIE must give me the accounting of disclosures within 60 (sixty) days, or tell me that it needs an extra 30 (thirty) days (or less) to prepare it.
I am entitled to one free accounting of disclosures in any 12 month period. Additional accountings will cost $_____________ each.
Date: ___________________________ Time: __________________ AM/PM
Signature: _____________________________________________________
If signed by someone other than the patient, indicate relationship: ______________
Print Name: _________________________________________________________
(legal representative)
Please scan and email to: info@sacvalleymedshare.org –OR-
Mail to: SacValley MedShare, P.O. Box 9217, Chico CA 95927-9217

SVMS-FORM-016.002 Request for an Accounting of Disclosures - English Page 2 of 3

SacValley

The Health Information Exchange
for California’s North Central Valley

MedShare

P.O. Box 9217
Chico, CA 95927-9217

Request for Accounting of Disclosures

For more information about your privacy rights, see the “Notice of Privacy Practices” available on our website at www.sacvalleymedshare.org, or by sending a written
request to SacValley MedShare, P.O. Box 9217, Chico CA 95927-9217.
If you believe your privacy has been violated, you may file a complaint with SacValley MedShare or with the Secretary of the United States Department of Health and
Human Services. To file a complaint with SacValley MedShare, send an e-mail to
info@sacvalleymedshare.org or by sending a written complaint to SacValley
MedShare, P.O. Box 9217, Chico CA 95927-9217.
You will not be penalized for filing a complaint.

SVMS-FORM-016.002 Request for an Accounting of Disclosures - English Page 3 of 3