LOS ANGELES COUNTY
DEPARTMENT OF MENTAL HEALTH
  Policy 501.03 Accounting of Disclosures of Protected Health Information
 
  PROCEDURES
  1. When a Los Angeles County Department of Mental Health (DMH) facility receives a request for an accounting of disclosures from a client staff shall:
     
    1. Provide the client with the Request for Accounting of Disclosures (MH 611) form.
       
      1. Clients making their request for an accounting by telephone or e-mail shall be sent a copy of the form. 
         
    2. Verify the requester’s identity prior to granting the request for an accounting.
       
    3. Maintain the form in the client’s medical record for a minimum of 10 years.
       
  2. DMH shall designate an individual or individuals who shall be responsible for processing Request for Accounting of Disclosures (MH 611).
     
    1. DMH shall document the titles of the persons or offices responsible for receiving and processing these requests.
       
  3. For each disclosure that must be recorded, the accounting must include the following information:
     
    1. Date of the disclosure;
       
    2. Name of the entity or person who received the Protected Health Information (PHI);
       
    3. If known, the address of the entity or person who received the PHI;
       
    4. A brief description of the PHI disclosed; and
       
    5. A brief statement of the purpose of the disclosure.
       
    1. Used to record disclosures.
       
    2. Maintained in a client’s medical record for a period of at least 10 years from the date of the last accounting.
       
  5. If, during the period covered by the accounting, DMH has made multiple disclosures of PHI to the same person or entity for a single purpose, or pursuant to a single authorization, the accounting may, with respect to such multiple disclosures, provide:
     
    1. The information set forth in Policy 501.03 Section II.B. for the first disclosure;
       
    2. The frequency, periodicity, or number of disclosures made during the accounting period; and
       
    3. The date of the last such disclosure during the accounting period.
       
  6. DMH shall respond to the client’s request for an accounting:
     
    2. Providing a copy of the completed Account Tracking Sheet; and
       
    3. No later than 60 days after receipt of such a request; 
       
      1. DMH may request an additional 30-day extension to act on the request.
         
      2. Only one extension period is permitted.
         
      3. DMH shall notify the client of the delay:
         
        1. In writing;
        2. Within the original 60-day time limit indication;
        3. State the reason(s) for the delay; and
        4. State the date by which the accounting will be provided.
           
  7. The first accounting of a client in any 12-month period must be provided at no charge.
     
  8. DMH may impose a reasonable, cost-based fee for each subsequent request for an accounting by the same client within the 12-month period, provided that DMH:
     
    1. Informs the client of the fee in advance.
       
    2. Provides the client with an opportunity to withdraw or modify the request for subsequent accountings in order to avoid or reduce the fee.
       
  9. All documents required to be created or completed under this policy and procedure will be retained for a period of at least 10 years from the date of its creation or the date when it was last in effect, whichever is later.