Request list of disclosures of medical information

What is an accounting of disclosures?

• An accounting of disclosures is a list of who has received your medical information for reasons other than treatment, payment, healthcare operations or disclosures specifically authorized by you. Health First may have disclosed your medical information without your written consent as required by federal regulations. Examples of these types of disclosures are listed on the Request for an Accounting of Disclosures form.

How do I request an accounting of disclosures?

• You will need to submit a Request for an Accounting of Disclosures form (pdf). The form must be signed and verification of identity is required.
• If using a Chrome Operating System, you must first download and save the form, then re-open it before you can enter data into the fields.
• The form can be submitted by email, fax, mail, or in person.
• Email to HIM Integrity Team at HIMIntegrityTeam@HF.org
• Main HIM location addresses and fax numbers are included on the form
• You may also visit / mail to the other facility HIM location addresses