Report a new Amendment Request

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 Date *

Date Range of Record(s) To Be Amended *

Facility *

Department

Patient

Name *

MRN

EMPI

DOB *

Phone *

Remove Patient

Add Another Patient

Request Description

Describe Entries or Documents Requiring Amendment and Dates for Each. *

If appropriate, attach a screen shot, photo, report, or other document to further describe this request.

Attach copies if available

Type of Visit

Would you like this amendment forwarded to anyone else?

Amendment Notification

Identify Recipients to Notify

Permission to Notify Recipients?

Name *

Phone *

Relationship
to Patient

Address *

City *

State *

Zip *

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.

Electronic Signature (Full Name) *

Today's Date *

New Amendment Request

Basic Information

Patient

Request Description

Amendment Notification

Please Identify Yourself Same as Patient

Please Identify Yourself
Same as Patient