Healthcare Urgent Care Revisions Form

HEALTHCARE URGENT CARE REVISIONS FORM

Patient Information

Original Visit Details

Facility/Clinic:

Provider/Attending Clinician:

Date of Visit:

Revision Request

Please indicate the specific portion(s) of the medical record you request to be revised and provide a concise statement of the requested change. Attach supporting documentation where available.

Attach copies of documents that support this request. Originals will not be returned. Include any witness statements, receipts, or outside records.

Authorization and Certification

I certify that I am the patient named above or the patient's authorized representative. I request that the facility review and, where appropriate under applicable law and facility policy, make the revision(s) described above to the patient's urgent care record. I understand that:

• the facility will review this request and may require additional documentation or verification before making any amendment;
• the facility may retain a record of the original entry where required by law and may add an addendum or notation rather than deleting original content;
• processing may take up to a reasonable period required for review, investigation, and compliance with legal requirements;
• I may be notified of the facility's determination and the facility may provide a rebuttal statement if the amendment is denied.

By signing below I authorize the facility to access, review and copy all records necessary to evaluate this request, including but not limited to diagnostic reports, medication records, and billing data related to the visit identified above.

I acknowledge that I have been informed of my rights regarding access to and amendment of protected health information. I understand that this request authorizes review of my protected health information as reasonably necessary to evaluate the revision request.

Processing and Contact

Processing Office/Department:

Contact Person for Follow-up:

Note: The facility may require verification of identity and may charge a reasonable fee for copies where permitted by law.

Certification and Signature

I certify under penalty of perjury that the information provided on this form is true and correct to the best of my knowledge. I understand that providing false information may subject me to civil or criminal penalties under applicable law.

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