Fort Worth Texas Solicitud de Contabilidad de Divulgaciones de Información de Salud Protegida - Request for Accounting of Disclosures of Protected Health Information
State:
Multi-State
City:
Fort Worth
Control #:
US-3581
Format:
Word
Instant download
Description
This form is used by an individual to request an accounting of the persons or entities to whom the individual's protected health information has been disclosed. Permitted exclusions from the accounting are also described.
Para su conveniencia, debajo del texto en español le brindamos la versión completa de este formulario en inglés.
For your convenience, the complete English version of this form is attached below the Spanish version.
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