Patient Request for Amendment Form

Patient Request for Amendment of Protected Health Information

Patient Name (required)

Street Address (required)

City (required)

State (required)

Zip Code (required)

Email (required)

Date of Birth (required)

Right to Request Amendment of Your PHI and Our Duties: You (or your authorized representative) have the right to ask us to amend protected health information (PHI) that we maintain about you in a designated record set. When required by law to do so, we will amend your information within 60 days of your request and will notify you when we have amended the information. We are permitted by law to deny your request to amend your medical information in certain circumstances, such as when we believe the information you have asked us to amend is correct. Red, White & Blue Fire Protection District is entitled to perform and bill for services based on PHI in its current form or upon which it has already relied until such time as the amended information becomes effective.

Request for Amendment of PHI:

Below, please describe the PHI that you are requesting us to amend and how this information should be amended with as much specificity as possible. Specify dates of service and other details that will allow Red, White & Blue Fire Protection District to accurately and completely fulfill your request. Please attach additional pages if necessary. (required)

Your Signature (required)

Confirm e-Signature

Review Electronic Records and Signatures Policy (required)

Read our Electronic Record and Signature Disclosure

I agree to use electronic records and signatures

Date (required)

Printed Name (required)

Relationship to Patient (required)

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Website Accessibility Statement

Red, White & Blue Fire Protection District (the "District") is committed to ensuring that its services are accessible to all members of the public. As part of this commitment, the District strives to provide an accessible website compatible with the Web Content Accessibility Guidelines (WCAG) version 2.1, AA, and commercial screen reading software. Features of the website are created to allow individuals with vision and other impairments to understand and use the website to the same degree as someone without disabilities.

If you need any special assistance or accommodations:

Contact our compliance support team via telephone at: (888) 765-1970

Ongoing Compliance Information

Compliance Coordinator

The District has designated a Compliance Coordinator for website disability-related accommodations. The Compliance Coordinator has received training in website accessibility and updates the site in accordance with those best practices and requirements.

Compliance Procedures

The District is working to ensure all website content complies with the Americans with Disabilities Act and controlling State laws. In an ongoing effort to continually improve and remediate accessibility issues, the website is regularly scanned to ensure ongoing compliance, and timely changes are made to any inaccessible content if found.

Accessible Documents Policy

The District is committed to providing all documents hosted on the website in an accessible format or making accessible alternatives available.

Linked Documents and Third Parties

Please note that this site may link out to third-party websites that do not have accessible content. This site may also include documents provided by third parties. While we cannot control the accessibility of content provided by third parties, we are happy to assist any member of the public with reading and accessing content on our site.

Report a Website Accessibility Issue

We are committed to your ability to access all content, and we will respond to all requests in a timely manner. If you need assistance or accommodations while accessing content on this website, please contact our Compliance Coordinator via the form below: