641

Form to request correction/amendment of ones PHI

(On your letterhead)

Form to request a correction of or addition to my personal healthcare information

Clients name ____________________________ Date of birth ___________________
Clients Address ________________________________________________________
Telephone______________________ Other identification(s) ____________________
This is page ___ of ____ pages
Date(s) or the part of clients record to be amended ____________________________
_______________________________________________________________________
Type(s) of information to be amended _______________________________________
_______________________________________________________________________
Please explain how the entry is incorrect or incomplete __________________________
_______________________________________________________________________
_______________________________________________________________________

What should the entry state in order to be more accurate or complete? ______________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Would you like this amendment sent to those to whom we have disclosed information in the past? If so,
please write below the name and address of the organization(s) or individual(s)
____________________________________________________________
_______________________________________________________________________

________________________________________________

_______________

Signature of client or his or her personal representative

Date

____________________________

________________________________________

Relationship to the client

Description of personal representatives authority

Decision a of the health care practitioner:

I will comply with this request.

I deny this request because the PHI :

q was not created by this organization
q is accurate, in my judgment.
q is complete, in my judgment.
q is not available to the client for inspection as permitted by federal law.
q is not part of clients designated record set.
q Other reason _______________________________________________________

_______________________________________________________________________
q

I will partly comply with this request. I indicate which parts I will amend and not
amend._________________________________________________________________

_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
If you, the client, disagree with my decision, please check the box here q.
You may write a Letter of Disagreement to the Privacy Officer stating your reasons for disagreeing and this
letter will be included whenever we disclose this part of your records. If you do not write this letter you can
ask us to send this Request for Amendment along with our reasons for denying your Request whenever I
send this part of your medical records to anyone. If you have any questions or want to know more, please
contact the Privacy Officer.
_________________________________________ ________________________
Signature of Health Care Practitioner

Date

Privacy Officer: Name _____________________________ Phone _______________

Address ________________________________________________________________