Healthcare Amendment Letters

Healthcare Amendment Letter

Patient Name:    Date of Birth:

Medical Record Number:    Facility / Provider:

Original Document Type:    Original Document Date:

Date of this Amendment Request:

Amendment Request Details

Please indicate the nature of the requested amendment (check all that apply):

Correct a factual error in the record

Add omitted information or clarification

Delete specific information from the record

Restrict disclosure or distribution of specified information

Other:

Amendment Specifics

Effective date for amendment:

Requested disposition of original document:

Replace original document with corrected version

Append corrected document to original record

Annotate original record to reflect correction (do not remove original)

Supporting Documentation

Date(s) of original entry(ies) to be corrected:

Provider Action Requested

Notify third parties of amendment (if applicable): Yes    If yes, list names/organizations:

Legal Certification and Authorization

I certify that the information provided in this amendment request is true and accurate to the best of my knowledge. I request the facility named above to investigate and amend the health information identified herein in accordance with applicable law. I understand the facility may require reasonable verification and may deny the request if criteria are not met; if denied I may submit a written statement of disagreement, which will be maintained with the record. I authorize release of any necessary information to validate this request.

I have read and understand the statements above and certify that I am the patient or the patient's authorized representative.

Contact Information

Preferred contact method:   Phone   Email   Mail

Office Use Only

Date received:    Investigation start date:

Outcome:   Approved   Denied

Processed by:    Date processed:

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