Form

641
(On to
yourrequest
letterhead)
aForm
correction
to request
of or
correction/amendment
addition to my personal
of ones
healthcare
PHI
informatio
nClients
Clients
Telephone
This
Date(s)
Type(s)
Please
_______________________________________________________________________
isexplain
page
or
of
name
Address
______________________
the___
information
____________________________
part
how
________________________________________________________
of
the
____entry
of
clients
to
pages
be is
amended
record
incorrect
Other
_______________________________________
toidentification(s)
beDate
or
amended
incomplete
of birth
____________________________
________________________
___________________
____________________
__ should the entry state in order to be more accurate or complete? __________
What
_______________________________________________________________________
Would you like this amendment sent to those to whom we have disclosed informatio
_______________________________________________________________________
____
n in the past? If so, please write below the name and address of the organizatio
n(s) or individual(s) __________________________________________________________
________________________________________________
_______________________________________________________________________
__
Signature
of client or his or her personal representative_______________
____________________________
Date
Relationship
to the client
________________________________________
Description of personal representatives a
DecisionqIawill
quthority
was
is
deny
of not
accurate,
complete,
the
not
comply
this
available
health
created
request
with
incare
by
my
this
tobecause
this
judgment.
practitioner:
the
request.
organization
client
the PHI
for:inspection as permitted by federal
qlaw. qI will
_______________________________________________________________________
Other
is not
partly
reason
partcomply
of_______________________________________________________
clients
with this
designated
request.record
I indicate
set. which parts I will am
end and not
amend.__________________________________________________________
If you,
_______________________________________________________________________
_______
You
may write
the client,
a Letter
disagree
of Disagreement
with my decision,
to the Privacy
please Officer
check thestating
box here
yourq.reaso
ns for disagreeing and this letter will be included whenever we disclose this pa
rt 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 ________________________________________________________________
_________________________________________
Signature
Privacy
Address
know
Officer:
of Health
more,Name
please
Care
_____________________________
Practitioner
contact the Privacy Officer.
________________________
PhoneDate_______________