Alden, NY · Erie County
Request for an Accounting of Disclosures
This form lets a patient or authorized representative request an accounting of protected health information disclosed by Erie County and submit the request to the county’s Chief Privacy Officer.
- licensed online notary
- ~15 min average
- Notarized PDF emailed
What you’ll need
- Government-issued photo ID
- Webcam-enabled device (laptop or phone)
- This form, ready to upload as a PDF
What this form is
Use this form to ask Erie County to account for disclosures of your protected health information, identifying the department, date range, and preferred delivery method. Complete and return it to the Erie County Chief Privacy Officer; the form requires notarization for requests sent by mail. An authorized representative must also provide a copy of the document showing their authority.
Who needs it
A patient or authorized representative seeking an accounting of protected health information disclosed by Erie County should complete and submit this form.
Why it needs a notary
The form contains an acknowledgment, and the individual referenced in the form must personally appear before the notary and acknowledge signing it.
How to get this notarized
- 1
Download the Form
Get the Request for an Accounting of Disclosures form from Erie County.
- 2
Fill Out the Request
Provide your contact details, select the department and date range, and choose how you want to receive the accounting.
- 3
Book an Online Notary
Arrange a remote appointment with a commissioned online notary for the form’s acknowledgment.
- 4
Sign on Video
Personally appear by video and acknowledge your signature before the notary.
- 5
Submit to Erie County
Return the completed form to the Erie County Chief Privacy Officer. Include proof of authority if an authorized representative is submitting it.
Preview the form
The blank PDF straight from Alden. Look it over, then upload your filled copy to start the notary session.
You’ll need ID and a webcam.
A licensed online notary will join you on video, verify your government-issued ID, witness your signature, and apply their seal. You’ll receive the notarized PDF by email when the session ends.
Frequently asked questions
- How do I submit this request to Erie County?
- Complete the form and return it to the Erie County Chief Privacy Officer at the address or email shown. Requests submitted by mail require notarization; an authorized representative must include proof of authority.
- Do I need to notarize this form?
- Yes, the form says notarization is required for requests submitted to Erie County by mail. It includes an acknowledgment for the individual referenced in the form to sign before a notary.
- Can I complete the notarization online?
- New York permits remote online notarization by a commissioned online notary. You can meet with the notary by secure video, present identification, and acknowledge your signature.
- Can a personal representative submit this request?
- Yes. The form includes space for a personal representative and asks for their authority; it also requires an authorized representative submitting the request to provide a copy of the appointing document.
- What time period can I request an accounting for?
- The form says the requested period can be no longer than six years, or three years when the accounting is from electronic health records. Confirm with the city, town or village if unsure.