Health Information Compliance Alert

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 this: Covered entities must respond to PHI amendment requests within 60 days of their receipt.

[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: _____________

 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: ________________________________