Division of Public Health
Disclosures of Individually Identifiable Health Information (IIHI)
Section: Non-Routine Disclosures
Decision to Disclose
Tracking Information Authority for or Reason for Date How Information was Approved By
Number Date Requested Requestor Requested Purpose of Disclosure Disclosure Denying Disclosure Disclosed Recipient Disclosed Date Approved
Notes: Tracking Number: Internal tracking number that can provide Cross-References to further information about Disclosure (example - location where orignal request is filed). Number should include DPHsection, for example "DPHLAB1".
Information Requested: Specific information requested/disclosed, include client name and/or ID number, if applicable.
Purpose of Disclosure: Brief description that can inform individual of the basis and reason for the disclosure.
Authority for Disclosure: (example - required by law citation if applicable).
Recipient: Organization or name, including address if known.
How Information was Disclosed: (examples - computer printout, fax paper record, telephone, mail or courier).
Approved By: Person who Approved Disclosure and Date Approved.
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Accounting of Disclosures