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Accounting of Disclosures Request Form - Mutual of Omaha

Accounting of Disclosures Request Form - Mutual of Omaha 2025

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The document is an 'Accounting of Disclosures Request Form' from Mutual of Omaha, allowing individuals to request a record of disclosures made regarding their protected health information. It outlines the necessary personal information required for processing the request, specifies the time period for which disclosures are requested, and notes that certain disclosures are exempt from accounting. The form must be signed by the requester or an authorized representative, and completed forms should be sent to Mutual of Omaha's Privacy Office.

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Click ‘Get Form’ to open it in the editor.
Begin by entering the name of the individual whose records are being requested in the designated field.
Fill in the address, including city, state, and zip code. Ensure all information is accurate for proper processing.
Provide a home telephone number for any follow-up communication regarding your request.
Input your Policy/Group Number and Subscriber Number if applicable, especially if coverage is through an employer.
Specify the period of time for which you wish to see disclosures made by Mutual of Omaha. Remember, you can request disclosures from any time after April 14, 2003.
Print your name, indicate your relationship to the individual, sign and date the form. Note that no request will be processed without a signature.
If acting as an authorized representative, include necessary documentation to validate your authority.
Once completed, return the form to Mutual of Omaha at the provided address.

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

How to request an accounting of disclosures?

Patients (or their Personal Representatives see Yale Policy 5038 - Personal Representatives) may request an accounting of disclosures by submitting a request in writing using the Request for Accounting of Disclosures of Protected Health Information form, or other sufficient written documentation requesting the

Can a patient request an accounting of disclosures?

An individual or his or her Personal Representative may request an accounting of Accountable Disclosures of the patients PII made by CDPH for up to three years preceding the request. The individual may make the request for an accounting in writing or orally.

What provides individuals with the right to request an accounting of disclosures of their PHI?

Pursuant to the Health Insurance Portability and Accountability Act of 1996, as amended by the Health Information Technology for Economic and Clinical Health Act of 2009, and all regulations promulgated thereunder (hereinafter collectively referred to as HIPAA), individuals have the right to request an accounting of

How do I request an accounting?

How to Get an Accounting. The California Probate Code gives beneficiaries the right to demand a full and complete accounting of the trusts assets, starting from the date of death of the decedent to the date of demand. A letter, directly to the trustee, making a demand for an accounting is the first step.