06-Accounting of Disclosures

Approved by: William Voss	Effective: April 26, 2024
Review: Annual	Revised:
Renewed By:	Renewed:

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Accounting of Disclosures

Policy Statement

River City TMS, PLLC must maintain a record of all known disclosures of protected health information (PHI) to external individuals and/or organizations, with certain exceptions. Patients have the right to request an Accounting of Disclosures that details the disclosures of their PHI made within six (6) years of the request.

Procedure

• Accounting of Disclosures §164.528(a)(1) 

  River City TMS, PLLC tracks all disclosures of a patient’s PHI on the Accounting of Disclosures of Protected Health Information form (Appendix E) which is kept in the patient’s medical record. The record contains dates of each disclosure, who the information was released to, the recipient’s address, a description of PHI disclosed, the purpose for the disclosure, and who released the information. 

  The Accounting of Disclosures does not include the following disclosures:

  Disclosure Context	Reference
  To carry out treatment, payment, and health care operations.	§164.506
  To individuals of PHI about them.	§164.502
  Incident to a use or disclosure otherwise permitted or required.	§164.502
  Pursuant to an authorization.	§164.508
  For the facility’s directory or to person’s involved in the individual’s care or for other notification purposes.	§164.510
  For national security or intelligence purposes.	§164.512(k)(2)
  To correctional institutions or law enforcement officials.	§164.512(k)(5)
  As part of a limited data set.	§164.514(e)
  That occurred prior to the compliance date for the covered entity.

• Patient Request §164.528(a) and §164.528(c)(2)

  Patients have the right to request an Accounting of Disclosures of PHI. This request must be provided in writing using the Request for Accounting of Disclosures form (Appendix D). The first request in a 12-month period is provided at no cost. Additional requests within the same 12-month period may be subject to a reasonable, cost-based fee (i.e. supplies, labor, postage). 

• Organization Response §164.528(b) and §164.528(c)

  Before processing the request, the patient will be informed of any fee in advance and provided with an opportunity to withdraw or modify the request. Upon receipt of the request signed by the patient, River City TMS, PLLC will gather all appropriate information:

  How does your organization gather the necessary information for an Accounting of Disclosures? (Select the procedure that is used, or describe your organizations specific process)

  • Collecting required information from any paper records.

  River City TMS, PLLC will provide the Accounting of Disclosures of Protected Health Information (Appendix E) within 30 days of the patient’s request. If more time is required to fulfill the request, River City TMS, PLLC will notify the patient in writing. Extensions will be no longer than an additional 30 calendar days.

  A copy of the patient’s request and the organization’s response will be filed in the patient’s medical record.

• Automatic Accountings

  Beyond providing an accounting of disclosures to patients that request one, an automatic accounting of this information may be required if PHI is disclosed without informing a patient or without receiving prior authorization. The purpose of this accounting is to inform the patient that their information has been provided to a third party without their authorization. These scenarios include, but are not limited to:

  • Subpoenaed PHI.

  • Workers' compensation cases.

  • Breach notifications.

  • Unauthorized disclosures to researchers or third parties.

• Temporary Suspensions §164.528(a)(2)

  A patient’s right to an accounting of disclosures may be temporarily suspended, if a health oversight agency or law enforcement official provides a written statement that the accounting to the individual would be likely to impede the agency’s activities. These suspensions work to exclude the disclosure, to the specified entity, from the accounting for a given period. In cases where this statement is made orally, River City TMS, PLLC will document the identity of the agency, the suspension time, and the statement. Suspensions will be limited to a maximum of 30 days from the date of the oral statement unless a written statement is submitted. Following this period, the excluded disclosures must be included in the accounting of disclosures.