Form Cvh-131a - Medical Record Examination Appointment

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CONNECTICUT VALLEY HOSPITAL
MEDICAL RECORD EXAMINATION APPOINTMENT
CVH-131a
Rev. 4/03
Name: _____________________________________________________________ Unit: _________________________
Your doctor has granted you permission to review your medical record.
YOUR APPOINTMENT to review your record has been scheduled for:
Date: _____________________ Time: _______________ Location: _________________________________________
The clinician assigned to review your medical record with you is:
If you wish to reschedule this appointment please contact the clinician named above or your Head Nurse.
NOTICE TO PATIENT:
If you wish to have a copy of something in your medical record, please ask the clinician reviewing the record with
1.
you for a REQUEST FOR COPY form (CVH-151). Indicate on the form the document(s) you wish copied.
Give the form to the Head Nurse on your unit, a Patient Advocate, or send it directly to the Health Information
Management. The Health Information Management will process your request and will notify you of the cost.
If while reviewing your medical record you find an error in the information recorded you have the right to request
2.
that this error be amended (corrected). Obtain a REQUEST FOR AMENDMENT form (CVH-522) from the clinician
reviewing the record with you.
Give the form to the Head Nurse on your unit, a Patient Advocate, or send it directly to the Health Information
Management. The relevant clinician will review the information you have stated was in error. If an amendment
(correction) is necessary, you will be notified of such; if the relevant clinician does NOT feel that the information is
incorrect, your request for amendment (form) will be filed in your record to note your disagreement with the specified
information.
3. If you disagree with any information recorded in your record, you have the right to submit a statement indicating
what you believe to be the accurate and complete version of the information in question. Your statement will be made
a permanent part of your record.
Give your statement that you wish filed in your medical record to your Head Nurse, a Patient Advocate or send it
directly to the Health Information Management for filing of your statement in your medical record.
______________________________________________
______________________________________
Signature of Head Nurse/Other Scheduling Appointment
Date Processed
Distribution by Unit Staff:
ORIGINAL – Patient
COPIES – Chart (Correspondence Section) and Review Clinician

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