When a patient wants a PHI correction, pull out this handy document. REQUEST FOR AMENDMENT OF THE MEDICAL RECORD [NAME OF ENTITY] Patient Name: __________________ Date of Birth: _________ Address:_____________________ Phone Number: ____________ After review of my medical record, I do not feel that the original documentation made by _________ accurately reflects my treatment, condition, or diagnosis on the following date _________ and should be supplemented with clarifying information in the form of an addendum to my medical record. I understand that my physician or health care provider may or may not supplement my record with an addendum based on my request. I understand that my physician or other health care provider is not allowed to alter the original documentation in my record. I understand that my request for amendment will be made a permanent part of my medical record and will be sent with any future authorized medical record request for information. I understand that [NAME OF ENTITY] will provide a response to this request within sixty days. I understand I have the opportunity to provide a statement of disagreement should my physician or health care provider deny my request. Reason for amendment: ______________________________________________________________________________________ I request the following correction/amendment be made on my medical record: __________________________________________ Signature: ____________________________ Date: _____________________________ PHYSICIAN OR HEALTH CARE PROVIDER RESPONSE In response to your request, a correction/amendment will be made part of your permanent medical record. Your request has been denied; however, your request is made part of your permanent medical record. The reason your request is denied: ____________________________________________________________________________________________________ Signature: _____________________________ Date: _____________ Date response sent to patient: ________________________________ Source: Reprinted with permission from the Oregon Association of Hospitals and Health Systems (OAHHS). Disclaimer: OAHHS does not make any express or implied representations or warranties about the accuracy of this information for any purpose or the suitability of this information for use.
Direct from the Oregon Association of Hospitals and Health Systems to your doorstep, here's a sample document your patients can use to request amendments to their protected health information and for your organization to respond to such requests.
Remember: Covered entities must respond to PHI amendment requests within 60 days of their receipt.
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