Request Amendment Form To Protected Health Information

REQUEST AMENDMENT to PROTECTED HEALTH INFORMATION

Please print all requested information to prevent delays in our response & provide completed form to your facility.

Patient Name: _________________________________________________________________________________________

Last

First

MI

Maiden or Other Name

Address:

City:________________ ST:

Zip: ____________

Date of Birth: ______-______-_____

Phone: ___________________________________________________

Entry to be amended: Date:__________________________Correction Type: _____________________________

Explain how the entry is incorrect or incomplete and what it should say to be correct.

________ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ___ ________ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ___ ________ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ___ ________ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ___ ________ ______ ______ ______ ______ ______ ____

________ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ___ ________ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ___ ________ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ___ ________ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ___ ________ ______ ______ ______ ______ ______ __

Would you like this amendment or denial sent to anyone we may have disclosed the information to in the past? If

yes, please provide name and address information.

NAME: _________________________________________________________________________________________________________________

ADDRESS: _________________________________________________________CITY:_____________STATE:_____________ZIP:______________

I understand that that my request will be processed within the time frames set forth by state law or within 60 days,

whichever less is.

OR

SIGNATURE OF PATIENT

DATE

PARENT/LEGAL GUARDIAN/AUTHORIZED PERSON

DATE

RELATIONSHIP TO INDIVIDUAL

FOR INTERNAL USE ONLY

Complete the sections below and place with patient records.









Date Request Received:

mail

in person

email

fax

Amendment Request has been:  Accepted



Denied

If denied, reason for denial is:

 Information was not created by this organization

 Information is not a part of patient’s designated record set

 Information is not available to the patient for access as required by federal law

 Information is complete and accurate

Comments:

Signature of Staff Member

Title

Date

Phone

Facility Name

Amend ENG – GCHJF56EN 08.15