CHS will provide the individual with an accounting that includes the following information:

1. The date of the disclosure
2. The name of the entity or person who received the PHI and the address, if known of such entity or person;
3. A brief description of the PHI disclosed; and
4. A brief statement of the purpose of the disclosure that reasonably informs the dividual of the basis for the disclosure; or, in lieu of such statement, a copy of a written request for a disclosure under 164.502(a)(2)(ii) or 164.512, if any.

To comply with this requirement, the inside back page of the medical record shall be used for documentation of disclosures that must be accounted for.  To facilitate this, CHS staff may use preprinted adhesive labels for permanent attachment to the record.  Upon a disclosure for which an accounting is required, the individual making the disclosure must enter the relevant data on the form, including initials of the individual making the disclosure for future identification.

If, during the period covered by the accounting, CHS has made multiple disclosures of PHI to the same person or entity for a single purpose, CHS may provide:

1. The information required for the first disclosure of the accounting period;
2. The frequency or number of disclosures made during the accounting period; and
3. The date of the last such disclosure during the accounting period.