REQUEST FOR AMENDMENT OF HEALTH INFORMATION
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SECTION A: CLIENT to complete the following information. |
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DATE: |
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CLIENT NAME: |
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BIRTH DATE: |
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CLIENT ADDRESS: |
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CLIENT PHONE NO.: |
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REC. NO.: |
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REQUEST:
I hereby request the Human Development Center to amend the following (check all that apply):
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¨ My case records |
¨ My billing records |
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¨ Other—please describe |
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Date(s) of information to be amended (e.g. Date of visit, treatment, or other health care services) |
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The information is incorrect or incomplete in the following manner: |
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I request this amendment for the following reason(s): |
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The information should be amended as follows: |
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I would like this amendment sent to the following persons who may have received my health information in the past (please specify name and address of the individuals or organizations): |
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I understand that the Division of Mental Health & Developmental Disabilities may or may not supplement the record with an addendum based on my request. I also understand that the Division of Mental Health & Developmental Disabilities is not able to alter the original documentation in the record under any circumstances. Regardless whether my request is granted or denied, I understand that this request will be made a part of my permanent record and will be sent as part of the record in response to any authorized requests for release of my health information.
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Signature of Client or legal representative: |
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Printed name of legal representative: |
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Relationship to Client: |
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SECTION B: HDC to complete the following information. |
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DATE OF RECEIPT OF REQUEST |
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Request for correction / amendment has been: |
¨ Accepted |
¨ Denied | |
If denied, check reason for denial:
¨ The PHI was not created by this agency.
¨ The PHI is not part of Client's designated record set.
¨ The PHI is not available to the Client for inspection as required by federal law (e.g. psychotherapy notes)
¨ The PHI is accurate and complete.
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Staff comments: |
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NOTICE TO Client/OTHERS
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Client and/or others notified of determination via one or more of the following (check all that apply): |
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¨ Attachment A (Notice of Acceptance of Amendment) sent to Client on: |
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¨ Attachment B (Notice of Denial of Amendment) sent to Client on: |
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¨ Attachment C (Notice of Acceptance of Amendment) sent to identified persons pursuant to Client authorization on: |
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You do have a right to file a complaint with our facility and may do so by contacting the Privacy Officer as follows: |
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Privacy Officer/HDC (813) 872-6250 FAX: (813) 872-6278 5904 N. Armenia Ave Tampa, FL 33603
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Signature of staff member: |
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Date |
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Print name and title: |
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Signature of Privacy Officer: |
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Print name and title: |
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SAMPLE LETTER ACCEPTING A REQUEST FOR AMENDMENT OF PHI
<Client ADDRESS>
<DATE>
Record #: <NUMBER>
Filed: <DATE>
Completed: <DATE>
Dear <Client LAST NAME>:
Thank you for submitting to us your “Request for Amendment/Correction of Health Information.” Your request was forwarded to our Privacy Officer for review.
Your request has been accepted, and the appropriate amendment has been made and added to your record. If you so indicated on your initial request, the amended information will be forwarded to the organizations or individuals you identified. If you did not indicate that we should forward the information, but would like us to do so, or if you would like us to forward the information to additional organizations or individuals, please contact our Privacy Officer as follows:
Privacy Officer/HDC
(813) 872-6250
FAX: (813) 872-6278
5904 N. Armenia Ave
Tampa, FL 33603
Thank you for providing us with this opportunity to serve you and improve the accuracy and completeness of your health information.
Sincerely,
Name and Title
SAMPLE LETTER DENYING A REQUEST FOR AMENDMENT OF
PHI
<Client ADDRESS>
<DATE>
Record #: <NUMBER>
Filed: <DATE>
Completed: <DATE>
Dear <Client LAST NAME>:
Thank you for submitting to us your “Request for Amendment/Correction of Health Information.” Your request was forwarded to our Privacy Officer for review.
Your request has been denied for the following reason(s):
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The information was not created by this |
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The information is not part of your |
If you disagree with this denial, you may file a written statement of disagreement with the Privacy Officer who may be contacted as follows:
Privacy Officer/HDC
(813) 872-6250
FAX: (813) 872-6278
5904 N. Armenia Ave
Tampa, FL 33603
Please limit your statement to one typewritten page or two handwritten pages. If you choose not to file a statement of disagreement, you may request that we include your Request for Amendment/Correction of Health Information, as well as this denial of your request, with any future disclosures of the protected health information that is the subject of the requested amendment.
Sincerely,
Name and Title
SAMPLE LETTER RESPONDING TO A STATEMENT OF DISAGREEMENT FOR DENIAL OF AMENDMENT OF PHI
<Client ADDRESS>
<DATE>
Record #: <NUMBER>
Filed: <DATE>
Completed: <DATE>
Dear <Client LAST NAME>:
We received your “Statement of Disagreement” in response to our letter notifying you that we denied your “Request for Amendment/Correction of Health Information.” As part of the amendment request procedure, your initial request, your statement of disagreement, and supporting documents were forwarded for further review to a third party within our organization, who was not involved in the original decision to deny your request.
After considering your initial request, our denial of the request, and your statement of disagreement, along with your medical record, the third party determined that:
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The initial ”Request for Amendment/Correction of
Health Information” that you submitted |
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Your request continues to be denied. Your request
for amendment, our denial of the |
Sincerely,
Name and Title