Department of Social Services PHI Disclosure Tracking Log
INFORMATION REGARDING INDIVIDUAL WHO IS SUBJECT OF DISCLOSURE
Individual Name:	Social Security No.
Street Address:	Birth Date:
City/State/Zip:	Other Identifier (e.g., DCN)
Details Regarding Information Disclosed
Specify Information Disclosed:
Claims Information
Entire Record
Medical Diagnosis
Other
Dates Covered in Disclosure:	From:	To:
Legal authority under which information was disclosed to the Agency/Company/Individual:
To a public health authority
To the Food and Drug Administration
To health oversight agencies
For judicial and administrative proceedings
To law enforcement officials
Other
Purpose of Disclosure Request:
At request of the individual or individual’s personal representative
Other
Check format which was disclosed:
Paper	Computer Disk	Microfiche	Fax	(Fax Number)
Other
Date information was disclosed:
Information Regarding Agency/Individual To Whom Information Was Disclosed
Name of Agency/Company/Individual:
Name of Individual to Whom it was Disclosed:
Title/Position of Individual:
Contact Name:
Address:
Phone Number:
Details Regarding Employee that Disclosed Information
Employee Name	Division	County/Location
Telephone Number	Social Security Number	User ID