PATIENT REQUEST FOR AMENDMENT OF PROTECTED HEALTH INFORMATION

NOTICE: The Health Insurance Portability and Accountability Act of 1996 (HIPAA) allows you to request an amendment to our records containing your Protected Health Information (PHI) defined by HIPAA as Individually Identifiable Health Information. Please use this form to describe the records and amendment to those records that you are requesting. 

 

 

Patient Name:                                                                                Birth Date:                                                             

Phone number:                                                                                                                                                             

Patient Address:                                                                                                                                                           

Date of entry to be amended:                                                            Type of entry to be amended:                         

 

I do hereby request my Affiliated Dental Provider, directly or through its administrative providers, to amend my PHI as set forth below.

 

Please explain how the entry is incorrect or incomplete. In your opinion, what should the entry say to be more accurate or complete? (Please attach separate pages as necessary.)

________________________________________________________________________________________________________________________________________________________________

 

________________________________________________________________________________________________________________________________________________________________

 

If the Affiliated Dental Provider agrees with your request and completes an amendment to the medical record, would you like this amendment sent to anyone to whom we may have disclosed the information in the past? If so, please specify the name and address of the person or entity.

 

What is your preferred communication regarding this amendment decision?

 

E-Mail:                                        Mail:                                   

 

I acknowledge that the amendment I am requesting may be refused for reasons permitted under HIPAA. I understand that if my request is denied I am entitled to a written explanation, and I may submit a written statement disagreeing with the denial. The written statement will be maintained in the medical record and included in future disclosures of the protected health information that is the subject of the amendment request.

 

If making this request for a patient other than myself, I certify I am the patient’s legally authorized personal representative and am requesting this amendment in good faith and in the best interest of the above-named patient. I understand INTEGRIS may require documentation establishing legal authority of personal representative for the above-named patient, including but not limited to, valid durable power of attorney for health care.

 

Signature of Person Submitting Request                                                            Date:                          

 

Print Name of Person Submitting Request                                                             Relationship to Patient: