DOEA Form 186 "Request for Accounting of Disclosures of Protected Health Information" - Florida

What Is DOEA Form 186?

This is a legal form that was released by the Florida Department of Elder Affairs - a government authority operating within Florida. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 2003;
  • The latest edition provided by the Florida Department of Elder Affairs;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of DOEA Form 186 by clicking the link below or browse more documents and templates provided by the Florida Department of Elder Affairs.

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Download DOEA Form 186 "Request for Accounting of Disclosures of Protected Health Information" - Florida

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Request for Accounting of Disclosures of
Protected Health Information
FLORIDA DEPARTMENT OF ELDER AFFAIRS
4040 ESPLANADE WAY
TALLAHASSEE, FLORIDA 32399-7000
As required by the Health Information Portability and Accountability Act of 1996 (HIPAA)
you have a right to request an accounting of disclosures of health information that
pertains to you.
REQUEST SECTION
I, __________________________(Patient name) hereby request an accounting of disclosures of
my protected health information that have occurred over the last _________________________.
(Time Period - Up to 6 years)
_______________________________ _______________________________
Signature
Date
REQUEST PROCESSING SECTION - INTERNAL USE ONLY
This section is to be completed by the reviewer:
Date received:
Reviewed by:
Chief Privacy Officer:
Review Date:
The requested disclosure accounting was processed on ________________________________.
(Date)
_______________________________ _______________________________
Signature
Date
DOEA Form 186 (04/03)
Page 1 of 1
Request for Accounting of Disclosures of
Protected Health Information
FLORIDA DEPARTMENT OF ELDER AFFAIRS
4040 ESPLANADE WAY
TALLAHASSEE, FLORIDA 32399-7000
As required by the Health Information Portability and Accountability Act of 1996 (HIPAA)
you have a right to request an accounting of disclosures of health information that
pertains to you.
REQUEST SECTION
I, __________________________(Patient name) hereby request an accounting of disclosures of
my protected health information that have occurred over the last _________________________.
(Time Period - Up to 6 years)
_______________________________ _______________________________
Signature
Date
REQUEST PROCESSING SECTION - INTERNAL USE ONLY
This section is to be completed by the reviewer:
Date received:
Reviewed by:
Chief Privacy Officer:
Review Date:
The requested disclosure accounting was processed on ________________________________.
(Date)
_______________________________ _______________________________
Signature
Date
DOEA Form 186 (04/03)
Page 1 of 1