Compliance and Privacy Links:

Request an Accounting Of Disclosures

You have the right to receive an accounting of disclosures of PHI made by us to individuals or entities other than to you for the six years prior to your request, except for certain routine disclosures. To request an accounting of disclosures of your PHI, you must submit your request in writing to the Privacy Officer. Your request must state a specific time period for the accounting (for example, the past three months). LIBERTY will act on your request within 60 days. The first accounting you request within a twelve (12) month period will be free. For additional accountings, we may charge you for the costs of providing the list. We will notify you of the costs involved, and you may choose to withdraw or modify your request at that time before any costs are incurred.

To request a copy, complete the <Accounting Of Disclosures Form> below:

First Name

Last Name

Address (line 1)

Address (line 2)

City

State

Zip Code

Phone

Email Address

I would like an accounting of the disclosures of my record from (start date)

I would like an accounting of the disclosures of my record through (end date)

Please only click Submit once