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Patient Request for Amendment Form

Patient Request for Amendment of Protected Health Information

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:
Confirm e-Signature
Read our Electronic Record and Signature Disclosure
Streamline Verify
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