According to the Health Information Portability and Accountability Act of 1996 you have a right to request that health information pertaining to you be amended if you believe that it is incorrect or incomplete. Your request will be reviewed by the appropriate persons involved in your care. If your request to amend is granted, your record will be revised or amended and you will be provided with a copy of that document. If your request is not granted, you will be provided with an explanation as to the reason. If your request is not granted, you have the right to submit a statement of disagreement that will accompany the information in question for all future disclosures.

Please fill in the following information:

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* 1. Date of Request

Date

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* 2. Facility (check all that apply)

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* 3. Patient Name

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* 4. Patient Date of Birth

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* 5. Patient Phone Number

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* 6. Patient Address

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* 8. Describe the information you want amended/supplemented (e.g., History & Physical, physician notes)

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* 9. Date(s) of information to be amended (e.g., date of office visit, treatment, or other health care services)

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* 10. What is the reason for making this request?

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* 11. Describe how the entry is incorrect or incomplete

If your record is amended, would you like us to provide the amended document to anyone? Please provide the contact information below:

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* 12. Entity Name

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* 13. Entity Address

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* 14. Entity Phone Number

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* 15. Entity FAX Number

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* 17. **Required** Upload Photo ID

RELEASE AUTHORIZATION
I understand that information in my health record may include information relating to Sexually Transmitted Disease, Acquired Immunodeficiency Syndrome (AIDS), Human Immunodeficiency Virus (HIV) and other communicable diseases, Behavioral Health Care/ Psychiatric Care, treatment of alcohol and/or drug abuse and genetic testing; my signature authorizes release of any such information.

I may refuse to sign this authorization form. I understand that Foundation Health Partners will not condition or deny treatment on my signing this authorization. I understand that I may revoke this authorization at any time, except to the extent that action based on this authorization has already been taken. Foundation Health Partners’ Notice of Privacy Practices explains the process for revocation, which includes a request in writing.

Unless I revoke this authorization earlier, it will expire 6 months from the date signed.

I understand that, if this information is disclosed to a third party, the information may no longer be protected by state, federal regulations and may be re-disclosed by the person or organization that receives the information.

I release Foundation Health Partners, its employees and agents, medical staff members, and business associates from any legal responsibility or liability for the disclosure of the above information to the extent indicated and authorized herein.

Typing my full name and date in the boxes below serves as my signature and authorization to release my information.

Signature of patient or legal representative:

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* 18. Full Name of Requester

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* 19. Today's Date

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* 20. Relationship to Patient

T