(To be kept separate from child(ren)’s medical records.)
Information contained in this document can be used to comply with the Privacy Rule requirements as mandated by the Health Insurance Portability and Accountability Act (HIPAA) to account for disclosures of protected health information.
Name and address of public health authority:
Centers for Disease Control and Prevention
National Center for Immunization and Respiratory Diseases
1600 Clifton Rd.
Atlanta, GA 30333
Purpose: The U.S. Public Health Service is committed to reaching Healthy People 2000 and 2010 objectives that at least 90 percent of children in the United States complete their primary vaccination series by their second birthday. To measure progress toward this goal, the Centers for Disease Control and Prevention (CDC) has accessed immunization records for the children listed below.
Description: The information reported to CDC included a confirmation of the patient’s characteristics (e.g., child’s name, gender and birth date) and various characteristics of the patient’s visits (e.g., date of most recent visit, number and type of vaccinations, dates of vaccinations). All information collected is held in the strictest confidence and will be used only to generate statistical summaries.
Child’s Name Date Requested Disclosure Date
| File Type | application/msword |
| File Title | Attachment D: HIPAA Accounting Form |
| Author | andersoe |
| Last Modified By | mom |
| File Modified | 2009-03-27 |
| File Created | 2009-03-27 |