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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 exceptions to what can be included in the 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, ensuring all details are 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. Remember, requests can be made for any time after April 14, 2003.
Print your name and relationship to the individual whose records are being requested. Ensure you sign and date the form at the bottom.
If you are an authorized representative, attach necessary documentation to validate your authority.

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Got questions?

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

Do patients have the right to request an accounting of disclosure?

What are disclosures in financial statements? Disclosures come at the end of a financial statement, sharing non-financial information to provide context for the financials. This information helps investors, lenders, and others make the best possible decisions.

What is a disclosure in accounting?

The Privacy Rule does not require accounting for disclosures: (a) for treatment, payment, or health care operations; (b) to the individual or the individuals personal representative; (c) for notification of or to persons involved in an individuals health care or payment for health care, for disaster relief, or for

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

Which disclosures require reporting for accounting of disclosures?

When is a Disclosure Accounting Required under HIPAA? Disclosures for treatment, payment, and healthcare operations. Disclosures to, or authorized by, the individual. Disclosures for notification purposes or for facility directories. Disclosures for national security or intelligence purposes.