Protected health information (PHI) may be disclosed without patient authorization (authorized Disclosures) in certain circumstances. These include but are not limited to:

• For Treatment, Payment, and Health care Operations (TPO)
• Public health authority
• The FDA
• The medical examiner or coroner after a patient has died
• As authorized by state or federal law or regulation

    If this practice makes a non-authorized disclosure, federal regulations require us to keep a log of these disclosures for six years. As has always been our policy non-authorized types of disclosures have never been made, and will not be done so in the future without your specific permission.

    A patient may request, in writing, an accounting of any non-authorized disclosures of his PHI. The patient is allowed one accounting per year at no charge. If a patient requests more frequent disclosures, this practice charges $25 for this service.

I, ___________________________, request that Brett Elliott, M.D. P.A. provide me with an accounting of any and all non-authorized uses and disclosures of my protected health information (PHI) since _______________ (date).

I understand that there is a charge for this information if I have previously requested this information within the last 12 months. I have been informed that the cost of this will be $25, which is payable prior to mailing of this information or upon its receipt if presented in person. I agree to be financially responsible for this fee.

Patient signature: __________________________________  Date: ______________

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This page was last updated on 02/10/2024