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Request for Correction/Amendment of Protected Health Information Patient Name:______________________________________ Date of Birth: ____/____/_______ Patient Address: Street: ______________________________ City, State Zip: _____________________________________
Type of Entry to be
amended (circle appropriate one):
________________________________________________________________ ________________________________________________________________ Please specify what the entry should say to be more accurate or complete. ________________________________________________________________ ________________________________________________________________ ________________________________ _____________________________ Signature of Patient or Legal Guardian Date
Amendment has been: Accepted, Denied, Denied in part, Accepted in part If denied (in whole or in part)*, check reason for denial:
PHI was not created by this organization PHI is not available to the patient for inspection in accordance with the law PHI is not a part of patient’s designated record set PHI is accurate and complete Comments from healthcare provider who provided service: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Name of Staff Member Completing Form: ______________________________ Title: __________________________________ ____________________________________________ ________________ Signature of Healthcare Provider Who Provided Service Date
*If your request
has been denied, in whole or in part, you have the right to submit a written
statement disagreeing with the denial to the practice, Attn: Lynne George,
Privacy Officer at Pain Specialists of Texas, 4927 Lake Ridge Parkway, #170
Grand Prairie, Texas 75051. If you do not provide us with a statement of
disagreement, you may request that we provide to you copies of your original
request for amendment, our denial, and any disclosures of the protected health
information that is the subject of the requested amendment. *Practice must inform patient that a written request is required, and that the patient is required to provide a reason to support the requested change. American Medical Billing Association 2003 – All Rights Reserved, Form Provided by American Medical Billing Association http://www.ambanet.net/AMBA.htm amba@ambanet.net |
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