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Request list of disclosures of medical information

You have the right to request a list of disclosures of your medical information. This is a list of the disclosures that were made for specific purposes after April 14, 2003. Any disclosures made for the purpose of treatment, payment, or healthcare operations are excluded from the accounting requirement. You may request one free list every 12 months.

To receive a list of disclosures, you may submit a Request list of disclosures form (pdf) by fax or mail to:

Holmes Regional Medical Center
Attn: Health Information Management, EMPI Team
1350 South Hickory Street
Melbourne, FL 32901

Fax: 321-434-8935

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