Valdosta State University

Request for an Accounting of Certain Disclosures of
Protected Health Information for Non-Treatment, payment, and Healthcare Operations (TPO) Purposes

* Speech Clinic

* Student Health Services

* Athletic Department

* Human Resources

* Other. Please Specify ___________________________________________

As a Patient/Employee, you have the right to receive an accounting of certain non-routine disclosures of your identifiable health information made by Valdosta State University for non-TPO purposes. Your request must state a time period that may not be longer than six (6) years and may not include dates before April 14, 2003. The first list you request within a 12-month period will be provided free of charge. For additional lists during the same 12-month period, you may be charged for the costs of providing the list; however Valdosta State University will notify you of the cost involved and you may choose to withdraw or modify your request.

To request an accounting of disclosures for non-TPO purposes made by Valdosta State University, you must submit your request in writing to the Privacy Officer at Human Resources, 1500 North Patterson Street, Valdosta, Georgia 31968.

Patient/Employee Name:________________________ Date of Birth:_________________________

Patient/Employee Address:

____________________________

                           Street

________________________________

                           Apartment #

________________________________

                                    City, State Zip

________________________________________                     _____________________________

Signature of Patient/Employee or Legal Guardian                         Date

FOR INTERNAL PURPOSES ONLY:

Date Request Received:____________