Request for Correction-Amendment of Protected Health Information

Request for Correction-Amendment of Protected Health Information
Patient Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Date
Patient Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I hereby request that One Community Health correct or amend my health records as follows:
Date From*

MonthDayYear
Date
Date To*

MonthDayYear
Date
Record Type*

Visit NotePrescriptionDiagnosisBilling RecordOther
Please explain how the entry is inaccurate or incomplete*
Please specify what the entry should say to be more accurate or complete*
I understand that One Community Health will review this request and may approve or deny this request as permitted by applicable law. I also understand that, if this request is approved, One Community Health will supplement my health record, but is not able to delete or alter the original documentation. Regardless of whether my request is approved or denied, I understand that this request will be made part of my permanent health record.
If the request is approved, the individuals or entities that should be notified include
If One Community Health denies this request, in whole or in part, you have the right to submit a written statement disagreeing with the denial to One Community Health’s Privacy Officer (849 Pacific Ave. Hood River, OR 97031, Attn: Privacy Officer). If you do not provide us with a statement of disagreement, you may request that we provide your original request for amendment and our denial with any future disclosures of the health information that is the subject of this request. Additionally, you may file a complaint with the Privacy Officer at 541-308-8383 or the Secretary of the U.S. Department of Health & Human Services Toll Free at 1-877-696-6775.
Signature*

Clear
Date*

MonthDayYear
Date
If signing as Personal Representative of above-named patient, please provide (Legal documentation must be on file):
Representative Name

First NameLast Name
Representative's Relationship to Patient
Should be Empty: