Mr-4643 - Request For Amendment Of Health Information Form
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1
2Oregon Health & Science University
Hospitals and Clinics
Health Information Services /
ACCOUNT NO.
Medical Correspondence
MED. REC. NO.
3181 SW Sam Jackson Park Rd.
NAME
Mail Code: OP17A
Portland, Or 97239-3098
BIRTHDATE
(503) 494-8521, Fax (503) 494-6970
Page 1 of 1
Stamp Patient Card Here
REQUEST FOR AMENDMENT OF HEALTH INFORMATION
SECTION A: Individual to complete the following information. (Please print)
NAME ____________________________________________________________________________________
Last
First
Middle
ADDRESS _________________________________________________________________________________
TELEPHONE NO. ___________________________
BIRTH DATE __________________________________
MEDICAL RECORD NO. _____________________
REQUEST:
1. Description or a copy of the health information I want amended (include provider name, date(s) of service
and type of information, i.e. lab test results, physician notes, etc.) (Please attach supporting documents as
necessary.):__________________________________________________________________________
____________________________________________________________________________________
2. I request that the health information be amended as follows: (Include attachment(s) as necessary):
____________________________________________________________________________________
____________________________________________________________________________________
3. I request this amendment for the following reason(s): _________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
4. If the amendment is accepted, I would like this amendment to be provided to the following persons who
have received my health information in the past (please specify name, address, and phone number of
the individuals or organizations):
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
I understand that accepted amendments will be added or linked to the original documentation and made
part of the permanent health record.
Date: _________________
Signature of Patient or Legal Representative ___________________________________________________
Printed Name of Legal Representative (If applicable) _____________________________________________
MR1449
MR-4643
ONLINE 6/03 (Supersedes 3/03)
- continued on reverse -
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