Disclosure Log Form

Under the HIPAA privacy rule, patients have a Right to an account of Disclosures. This gives patients the right to receive a record of certain disclosure of the protected health information (PHI) made by a covered entity or its business associate.

An Accounting of Disclosures is a documented list of instances when a patient’s PHI was shared without their authorization, specifically for purposes other than treatment, payment, or healthcare operations, and includes information such as:

• The date of each disclosure
• The name (and address, if known) of the entity or person who received the information
• A brief description of the information disclosed
• The purpose of the disclosure

This right excludes certain types of disclosures. These exceptions include

• disclosures made for treatment, payment, and healthcare operations
• disclosures made directly to the individual
• incidental disclosures
• disclosures made with the individual's authorization

Key Points:

• Patients can request an accounting of disclosures once every 12 months free of charge.
• Covered entities must respond within 60 days, with a possible 30-day extension.
• The accounting covers disclosures from the previous six years
• Disclosures for law enforcement, public health, and legal requirements may be included, unless specifically exempted.

TLD Systems clients can find the disclosure log form under Forms on their Main Menu.

TLD Systems provides the support and tools for offices to be HIPAA compliant. Reach out today if you have questions or want to learn more about how we can support your office on your journey to HIPAA compliance. Call (631) 403 6687, menu option 3 or email info@tldsystems.com