Request for Accounting of Disclosures of Health Records DHS 2096 11/11

Request for Accounting of Disclosures of Health Records

For use by Department of Human Services (DHS) and Oregon Health Authority (OHA) clients requesting an accounting of disclosures. Name: (print) ID number: (case, prime, reservation number or SSN) Client’s mailing address:

Record holder: (office, district) Date of birth:

Location of record: (address) Date of request:

Submit this request to the office where services were received.

You can ask for a list of disclosures of your protected health information made by the Department of Human Services (DHS) or the Oregon Health Authority (OHA). If you would like this information, please consider the following:

 The list is free once every twelve months. DHS or OHA may charge you for additional lists in the same twelve-month period.  DHS and OHA will not list disclosures made more than six years before your request.  DHS and OHA will not list disclosures made earlier than April 14, 2003.  DHS and OHA may not list disclosures of protected health information related to treatment, payment or health care operations.  DHS and OHA will not list disclosures that you authorized. I am asking for a list of disclosures for the following period of time: (be specific) From: To: Full legal signature of individual or authorized personal representative: Date:

Personal representative authentication: Relationship to client:

DHS or OHA staff only. Approved Delayed If delayed we will act on your request by: Reason for delay:

See other side for client rights information Page 1 of 2 MSC 2096 (11/11) (DHS or OHA representative signature) (Date)

Your right to an accounting of disclosures:  You have a right to request an accounting of disclosures made by DHS or OHA of your information.  You have a right to have an answer to your request within 60 days. If there are delays in getting you the answer, you will be notified in writing and this delay cannot be more than an additional 30 days.  Your first request for an accounting in a twelve-month period is free. You may be charged for additional requests in the same twelve-month period. You have a right to file a complaint if your request for an accounting of disclosures is delayed beyond the timeframe mentioned above.

Complaints may be directed to any of the following: State of Oregon Department of Human Services Governor’s Advocacy Office, 500 Summer St. NE, E17, Salem, Oregon 97301-1097 Phone: 1-800-442-5238, FAX: 503-378-6532, Email: [email protected]

Oregon Health Authority, Privacy Officer 500 Summer Street NE, E24, Salem, OR 97301 Phone: 503-945-5780, FAX: 503-947-5396, Email: [email protected]

U.S. Department of Health and Human Services, Office for Civil Rights (For health information only.) Medical Privacy, Complaint Division, 200 Independence Avenue, SW HHH Building, Room 509H, Washington, D.C. 20201 Phone: 866-627-7748, TTY: 886-788-4989, Email: [email protected]

For current or former patients of the Oregon State Hospital (OSH) or Blue Mountain Recovery Center (BMRC): OSH – Director of Consumer and Family Services BMRC – Superintendent 2600 Center St. NE, Salem, OR 97301 2600 Westgate, Pendleton, OR 97801 Phone: 503-945-7132 Phone: 541-276-0810 Extension: 236

This document can be provided upon request in alternative formats for individuals with disabilities or in a language other than English for people with limited English skills. To request this form in another format or language, contact your local office. For a list of local offices please see www.oregon.gov/DHS/localoffices/index.shtml.

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