Forms Catalog Document - 913 :-: IHS :-: Request for an Accounting of Disclosures

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Request for an Accounting of Disclosures

This form is used to request for an accounting of disclosures of health information in a specified time period. The requestor can also request disclosure of a certain type(s) or disclosure to a specific person/entity.

Form #: 913
Agency: Department of Health and Human Services
Bureau: Indian Health Service
Common Name: Accounting of Protected Health Information Disclosures

	TYPE	PAGES	SIZE (KB)	CAPABILITY	WHAT'S NEEDED
	Form Only	1	255	[3] Fillable + Printable	Adobe Reader Download
	Form Only	1	50	[3] Fillable + Printable	Other Client Software

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