Medical Record Amendment Request

Patient instructions for requesting an amendment to your medical record:

1. You have the right to request an amendment to your medical record if you believe the information is incorrect or incomplete.

2. To request an amendment to your medical information, fill out the Amendment Request Form completely and accurately. In the Dispute and Requested Correction field, please describe exactly how the disputed documentation is incorrect and/or incomplete. Then write exactly what you think the documentation should state to be accurate and/or complete. 

3. Amendment requests will be handled on a case-by-case basis including consulting with your physician about the requested changes. You will be notified of the acceptance or denial of your request within 60 days of its receipt. If there is a delay, you will be notified in writing on a one-time 30 day extension. The notification will include a reason for the delay and the date by which the action will be completed.

4. If your request has been denied, you have the right to submit a written statement of disagreement to our office manager at [email protected] 

5. You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services. http://www.hhs.gov/ocr/privacy...

6. The Amendment Request and any additional documents related to the request will become a part of your permanent medical record and may be disclosed to future requestors as it relates to the subject of the amendment.


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Call the office if you have active symptoms or an issue that need an immediate response. Messages via this form will be answered in 2-3 business days.


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