Saint Therese Home, Inc.
Resident Name ________________________ Medical Record #_____________________
Other Name(s) ____________ DOB _______ Social Security #______________________
I request that the facility provide me with an accounting listing the disclosures of my protected health information made by St. Therese Home, Inc. for the following time period:
From: _________ to __________.
I understand that I am entitled to receive a listing of certain disclosures by the facility, not including disclosures made for treatment, payment or health care operations or other excepted purposes.
Please provide me with a list on:
q Paper
q Electronically
Mail or e-mail to: _______________________________
_______________________________
_______________________________
I understand that I am entitled to an accounting free of charge every 12 months, and that I may be charged if I request any additional accountings within the same 12 months.
I understand that I will be notified of the cost involved and will have the opportunity at that time to withdraw or modify my request before any costs are incurred.
_______________________________________ ___________________________________
Signature
of Resident/Responsible Party Relationship
to Resident if Signed by Res. Party
__________________________________________ ______________________________________
Date of Resident’s/Responsible Party’s Signature Reason Resident Unable to Sign