Request for [insert physician/clinic name] to Amend Health Information

 
Patient Name:_____________________________ Date of birth:___________________

Previous Name:________________________________ 
Patient Mailing Address:__________________________________________ 

I request a change to my records. 
Please explain what the information in your record should say to be more accurate or complete. If you need additional space, please include a separate page. Date of record: ____________________

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

___________________________________                       _____________________
Patient or legally authorized individual signature                        Date

________________________________________________________________________
Relationship to patient if signed on behalf of the patient by parent, legal guardian, personal representative, etc.

We will review your request and respond within 60 days of receiving your request. A copy of your request will be added to your record. 
If we make the change and you agree, we will send it to anyone we know has received the information in the past. We will also send the amendment to anyone you identify.
To be completed by [insert clinic/healthcare facility name]
Date Received____________________ Correction/Amendment has been: 
 Accepted             Denied – Letter Sent
 Review of this request has been delayed due to _________________________________
Your request will be processed by the following date ______________(not later than 90 days after the request).
If denied, check reason for denial:
 This health information was not created by this organization.
 This request does not pertain to the patient’s medical and financial records. 
 By law, this health information is not available to the patient and cannot be amended.  The existing health information is accurate and complete.
____________________________________________          ____________________
Name of reviewing department or position                                                      Date

(Document provided to MIEC policyholders with permission from PIAA)

 

Return to MIEC HIPAA "Starter Kit"