641 Request Amendment of Your PHI
641 Request Amendment of Your PHI
641 Request Amendment of Your PHI
What should the entry state in order to be more accurate or complete? ______________
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Would you like this amendment sent to those to whom we have disclosed information in the past? If so,
please write below the name and address of the organization(s) or individual(s)
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_______________________________________________________________________
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Date
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q
I will partly comply with this request. I indicate which parts I will amend and not
amend._________________________________________________________________
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If you, the client, disagree with my decision, please check the box here q.
You may write a Letter of Disagreement to the Privacy Officer stating your reasons for disagreeing and this
letter will be included whenever we disclose this part of your records. If you do not write this letter you can
ask us to send this Request for Amendment along with our reasons for denying your Request whenever I
send this part of your medical records to anyone. If you have any questions or want to know more, please
contact the Privacy Officer.
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Signature of Health Care Practitioner
Date