ࡱ>  ^@\pmbresna1 (2nd edits) Ba==xxL;"8X@"1Arial1Arial1Arial1Arial1Arial1Arial1Arial1Arial1Arial"$"#,##0_);\("$"#,##0\)!"$"#,##0_);[Red]\("$"#,##0\)""$"#,##0.00_);\("$"#,##0.00\)'""$"#,##0.00_);[Red]\("$"#,##0.00\)7*2_("$"* #,##0_);_("$"* \(#,##0\);_("$"* "-"_);_(@_).))_(* #,##0_);_(* \(#,##0\);_(* "-"_);_(@_)?,:_("$"* #,##0.00_);_("$"* \(#,##0.00\);_("$"* "-"??_);_(@_)6+1_(* #,##0.00_);_(* \(#,##0.00\);_(* "-"??_);_(@_)                + ) , *   ( *8@ @  @ @     *8 "8 )8 ` Sheet1Sheet2Sheet3`i Date Received Disclosed ByName of Requestor*Address* (if known)Purpose*PHI Disclosed*Date Disclosed*,* Fields required by HIPAA privacy standardsDisclosure Tracking Log$Requested By (Individual/Legal Rep):Staff Completing RequestDate Provided:'Requests for Accounting of Disclosures:Date RequestedDate Range RequestedKey:^Date Received: the date request is received to disclose or release information when applicableFPHI disclosed: brief description of the information disclosed/released>Date disclosed: date the information was released or disclosedQDisclosed by: staff member processing the request and disclosing the information:eAddress: if know, the address of the entity or person requesting information be disclosed or releasedPurpose: brief description of the purpose of the disclosure to reasonable inform the individual of the basis of the disclosure. Pursuant to:^Name of requestor: name of entity of person requesting information to be disclosed or releasedKPursuant to: identify waiver of authorization, law or public health purpose#This log provides tracking of disclosure of protected health information. Please record disclosures make pursuant to a waiver of authorization or as required by law or public health purposes. It is not necessary to track disclosures made pursuant to an authorization or of limited data sets. " gy  ^@ "]  dMbP?_*+%*'&L&"Arial,Bold"Patient Name: ID Number:;8&L&"Arial,Italic"&8Disclosure Tracking Log Draft 2 (JHB)&333333?'(\?()\(?)333333?MTrauma HP 4M Plus@w XX@MSUDHP LaserJet 4M Plus<d "dXX(\?zG?U} I } $} } I} I}  } I }  "  h @             ;                            <&&zP ! !T>@7 ^@ n  dMbP?_*+%"??U>@7 ^@ u  dMbP?_*+%"??U>@7 Oh+'0 PXx Disclosure Tracking Log鶹ý harrisjkis Microsoft Excel@ׂJX@pɩ@ߖH՜.+,0 PXx  鶹ýs2 Sheet1Sheet2Sheet3  Worksheets Root Entry F@)'VWorkbookSummaryInformation( DocumentSummaryInformation8