Request for an Accounting of Certain Disclosures of Protected Health Information

Request for an Accounting of Certain Disclosures of Protected Health Information

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    As a patient of UA Little Rock Health Services, you have the right to receive an accounting of disclosures of your identifiable health information (including those for treatment, payment, and healthcare operations) made by UALR Health Services and our business associates. Your request must state a time period, which may not be longer than three (3) years and may not include dates before April 14, 2003. Your first request within a 12-month period will be provided free of charge. For additional lists during the same 12-month period, you may be charged for the costs of providing the information. However, Health Services will notify you of the cost involved, and you may choose to withdraw or modify your request. To request an accounting of disclosures made by UA Little Rock Health Services or by our business associates, your request must be in writing addressed to our Privacy Officer at the following address: UA Little Rock Health Services, 2801 S. University Ave., DSC 102, Little Rock, AR 72204, ATTN: Charlotte Beck, Privacy Officer
  • Your typed name reflects your legal and binding signature.