New Amendment Request

Please use this form to request an amendment or correction to your medical record. Fill in as many of the fields below as possible. This form will be sent to your organization's patient privacy department for review and follow-up.

For additional information on a field, click on the '?' icon after the field label.

"PHI" stands for Protected Health Information, which in general is any demographic, clinical or financial information that is identifiable to a specific person.

For immediate assistance please contact the Corporate Privacy Office at (866) 898-8891 or (910) 715-2434

Basic Information



Request Description

Amendment Notification

Please Identify Yourself

To electronically sign this document, please type your name USING THE SAME SPELLING AS ENTERED ABOVE and enter the current date. By electronically signing and submitting this form, you are certifying that the information above is accurate and that you are either the patient identified above or their legal representative. You are also consenting to submit this request electronically and to receive responses electronically.