Medical Correction Consent Form

MEDICAL CORRECTION CONSENT FORM

WHEREAS: Patient named below is the subject of certain health records maintained by the Provider identified below, and Patient seeks correction of a specific entry in those records;

WHEREAS: Provider maintains medical records in accordance with applicable law and has established procedures for review and, where appropriate, correction or annotation of health record entries; and

WHEREAS: The parties desire to set forth the scope, authorization, and terms under which such correction shall be processed and documented.

Patient and Record Identification

Patient Name:

Date of Birth:    Medical Record ID:

Provider Name:

Scope of Correction

Describe the specific entry or entries to be corrected, including the date(s) of the original entry, location in the record, and the exact correction requested.

Lab report(s) attached    Imaging or radiology report(s) attached

Discharge summary or operative note attached    Other:

Payment Terms

The parties agree that any fees associated with review, copying, or correction of the medical record shall be charged as set forth below. Any fees charged shall comply with applicable law.

Term and Termination

This Consent becomes effective on the date signed by the Patient below and shall remain in effect until the correction process has been completed and documented, unless earlier terminated in accordance with this section.

Effective Date:    Expected Completion Date:

Either party may terminate this Consent for any reason upon written notice to the other party. Notice of termination shall be provided at least days prior to termination, except that termination does not relieve either party of obligations incurred prior to the effective date of termination.

Confidentiality

The parties acknowledge and agree that all medical information and supporting documentation exchanged or relied upon in connection with the requested correction are protected health information. Provider shall maintain confidentiality and comply with all applicable privacy laws and regulations. Provider may disclose the corrected entry or an addendum to parties to the extent required by law or necessary for continuity of care.

Patient acknowledges that intentionally submitting false information for the purpose of altering a medical record may be subject to civil or criminal penalties under applicable law.

I acknowledge receipt of a copy of this Consent and understand the confidentiality provisions above:

Governing Law

This Agreement shall be governed by and construed in accordance with the laws of the State of , without regard to principles of conflict of laws.

Entire Agreement

This Consent constitutes the entire agreement between the parties relating to the subject matter herein and supersedes all prior understandings, agreements, or representations, whether written or oral, regarding correction of the referenced medical record. Any amendment must be in writing and signed by both parties.

Patient Certifications and Authorization

By signing below, I certify under penalty of perjury that the information and documentation provided in support of this request are true and correct to the best of my knowledge. I authorize Provider to review and, if appropriate, correct or annotate the medical record entry described above in accordance with Provider policies and applicable law.

I further authorize Provider to communicate with designated third parties for purposes of verifying facts or obtaining records necessary to evaluate this correction request:

Sign Now