HIPAA Request for Amendment of Protected Health Information

HIPAA REQUEST FOR AMENDMENT OF
PROTECTED HEALTH INFORMATION

Printable Version

Patient's Full Name

Address

City/Town

State/Province

ZIP/Postal Code

Patient's Date of Birth

Patient or Representative's Phone

Please enter the patient or representative's email address

The email address entered will receive a copy of this signed request.

Does the patient have a MyChart account?

Yes

Don't know

I hereby request that St Charles Health System (SCHS) amend (please check all boxes that apply):

My medical records

My billing records

My records used by or for St. Charles to make decisions about my care

All of the above as specifically described below

I understand that St. Charles Health System (SCHS) may deny this request as permitted under Federal law and that I will be informed by SCHS concerning the basis for the denial along with instructions concerning my right to submit a statement disagreeing with such denial. I further understand that SCHS will notify me as of its decision to accept or deny my request within 60 days of receiving this request. If SCHS is unable to comply with my request within this timeframe, I understand that SCHS may extend the applicable deadline for up to an additional 30 days by notifying me in writing.

Describe the information you want amended (e.g., procedures, nursing/physician notes, test results)

Date(s) of information to be amended (e.g., date of office visit, treatment, or other health care services)

What is your reason for this request?

How is the entry incorrect or incomplete?

What should the entry say to be more accurate or complete? (Please be as specific as possible)

Do you know of anyone who may have received or relied on the information in question (such as your doctor, pharmacist, health plan or other health care provider)?

Yes

Don't know

If yes, please specify the name(s) and address(es) of such organization(s) or individual(s)

Patient Signature

Please use your mouse to sign in the grey box below. If on a tablet or smartphone, sign using your finger/stylus.

Personal Representative Name (if applicable)

Relationship to patient

Personal Representative Signature (if applicable)

Please use your mouse to sign in the grey box below. If on a tablet or smartphone, sign using your finger/stylus.

HIPAA REQUEST FOR AMENDMENT OF PROTECTED HEALTH INFORMATION

HIPAA REQUEST FOR AMENDMENT OF
PROTECTED HEALTH INFORMATION