SAMPLE LETTER DENYING REQUEST TO AMEND PHI
 

Name
Company
Street
City/ST/ZIP

Dear            :

 
We received your request to amend your health information record. We reviewed your request. Unfortunately, we cannot honor your request because:
___ This health information was not created by this organization.

___ By law, you may not access the health information and may not amend it.

___ Your request does not pertain to your medical and financial records.

___ The existing health information is accurate and complete.
 

You may contact [insert name/title of person] at our office at [insert telephone number and address] if you want to write a brief statement of disagreement to be added to your medical record. This is your right. It may include:

  • the reason(s) you believe the health information should be amended; 
  • why you disagree with this decision to deny your request;
  • that we include your statement in all future disclosures.

If you do not submit a statement of disagreement, you may request that in future disclosures we include a copy of:

  • your original request to amend the health information, and 
  • this letter.

 
If you wish to make this request:
  • sign here ______________________________________; and
  • return this form to us.

If you believe your privacy rights have been violated, you may deliver a written complaint to [insert name/title of person] at our office at [insert telephone number and address]. You may also file a complaint with the Secretary of Health and Human Services.

We respect your right to file a complaint with us or with the Secretary of Health and Human Services. If you choose to take this action, we will not retaliate against you!

Sincerely,
[Privacy Officer or physician’s name]

 

(Document provided to MIEC policyholders with permission from
Physician Insurers Association of America)

 

Return to MIEC HIPAA "Starter Kit"