Accounting of Disclosures Request Form

CRISP offers patients the opportunity to request an accounting of disclosures for their medical records contained within the CRISP database. This request, which can be made twice a year free of charge, will inform you which healthcare providers, if any, have accessed your medical records through CRISP services. Upon receipt of your request, CRISP will begin to process your accounting of disclosures. The results will be sent to you within 4 weeks.

Instructions: In order to submit your request online, please complete this form. You must also attach a copy of your government-issued photo ID (e.g., driver’s license, passport, or identification card).

If you do not want to submit a request online, you can download a form from the CRISP website. Please follow the instructions on that form to submit your request.

How would you like to receive your report from CRISP?
If you would like to receive the results of this request via email, please provide your email address: