Accounting of Disclosures Request Form for Walmart and Sam's Club
This form is used to request an accounting of disclosures of your Protected Health Information (PHI) made by Walmart and Sam's Club Pharmacies, Vision Centers, Opticals or Care Clinics. It provides a detailed list of disclosures made by these entities in the six years prior to your request. The form should be submitted separately for each location where you seek an accounting of disclosures.
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How do I fill this out?
To fill out the Accounting of Disclosures Request form, you need to provide your personal and contact information, specify the time period for the accounting, and list the Walmart or Sam's Club location for which you are requesting the disclosure information. Finally, sign and date the form. Make sure to submit a separate request for each location.
How to fill out the Accounting of Disclosures Request Form for Walmart and Sam's Club?
1
Enter your personal and contact information.
2
Specify the time period for the accounting of disclosures.
3
List the Walmart or Sam's Club location for the disclosure request.
4
Sign and date the form.
5
Submit the form to the specified location.
Who needs the Accounting of Disclosures Request Form for Walmart and Sam's Club?
1
Patients who want to track disclosures of their PHI by Walmart or Sam's Club.
2
Legal representatives managing healthcare documents for a patient.
3
Individuals auditing their medical disclosures.
4
Patients or guardians requesting historical PHI disclosures.
5
Healthcare compliance officers ensuring correct information handling.
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What are the instructions for submitting this form?
Submit the completed form to the specific Walmart or Sam's Club location, including the city, state, and store/club number. For facsimile submission, fax to the Legal Department at (479) 204-9696. Ensure all details are accurate and the form is signed. Advised to keep a copy for your records.
What is the purpose of this form?
The purpose of the Accounting of Disclosures Request form is to provide individuals with a clear record of their Protected Health Information (PHI) disclosures made by Walmart and Sam's Club. Healthcare organizations are required to maintain transparency and accountability in handling sensitive health information. This form ensures patients are aware of who accessed their PHI and for what purpose.
Tell me about this form and its components and fields line-by-line.
- 1. Patient Information: Collects personal details such as name, date of birth, address, and contact number.
- 2. Request Information: Allows the requester to specify the time period and facility of the disclosure request.
- 3. Signature and Date: Includes the signature of the patient or their representative and the date of signing.
- 4. For Office Use Only: Internal section for store or club number, request status, and other administrative details.
What happens if I fail to submit this form?
Failing to submit this form means you won't receive the accounting of disclosures of your PHI from Walmart or Sam's Club.
- Incomplete Records: Lack of submitted requests results in incomplete disclosure records.
- Information Gaps: Without submitting, there will be gaps in tracking who accessed your PHI.
- Potential Issues: Unsubmitted forms can lead to unresolved questions regarding your health data.
How do I know when to use this form?
- 1. Medical Audits: When auditing medical records for accuracy and completeness.
- 2. Legal Review: For attorneys or legal representatives to review PHI disclosures.
- 3. Personal Records: To maintain personal records of who accessed your PHI.
- 4. Insurance Claims: Ensuring the correct handling of your data for insurance purposes.
- 5. General Awareness: Staying aware of how your health information is shared and used.
Frequently Asked Question
How do I fill out the Accounting of Disclosures Request form?
Use PrintFriendly's editor to input your personal and contact information, specify disclosure period, and sign the form.
Can I edit the PDF form before submitting?
Yes, PrintFriendly allows you to make necessary edits directly on the PDF before finalizing it.
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You can digitally sign the form within PrintFriendly's editor by adding your electronic signature.
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How can I ensure my form is filled out correctly?
Carefully review all the filled sections and use PrintFriendly's tools to edit any mistakes before saving.
Where do I submit the completed form?
Submit the form to the Walmart or Sam's Club location listed on the document. Faxing might be required for the Legal Department.
What if I need to request disclosures from multiple locations?
You need to submit a separate form for each Walmart or Sam's Club location where you request disclosures.
Why is tracking PHI disclosures important?
Tracking PHI disclosures ensures your health information is managed correctly and securely by healthcare providers.
What information do I need to provide?
Provide your name, contact details, the period for which you need disclosures, and the Walmart or Sam's Club location.
Can I save the form after editing?
Yes, once you complete and review your edits, you can save the final document on PrintFriendly.
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