Managing Amendments in an HIE Environment. Appendix B AHIMA Sample Patient Request to Amend the Health Record
Patient Name:_______________________________________________________________________
Date of Birth:________________________________________________________________________
Address: ____________________________________________________________________________
City:_____________________________________ State:_______________ Zip Code: ______________
Home Phone: (_______)____________________ Work Phone: (_______)________________________
I have reviewed my health record; I do not feel the information in the record made by ____________________________________________ is correct.
This date(s) of service ____________________________________________ should be updated with the following information:
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
This form may be returned to your clinic or mailed directly to: [insert name of organization and address/fax number]
Signature: ______________________________________________________Date: _________________
AHIMA Sample Provider Response
An amendment will be made to your permanent health record.
A partial amendment will be made to your permanent health record. The following information will be amended per the request:
_______________________________________________________________________________________________________________________________
This request for an amendment has been made a part of your permanent record; however, your request to amend your health record directly has been denied for the following reasons: _______________________________________________________________________________________________________________________________
Provider Signature:__________________________________________
Date: _______________________________________________________
If you disagree with the provider, you may submit a written statement of disagreement.
(Attach copy of Statement of Disagreement for patient)
Reference: AHIMA. “Amendments in the Electronic Health Record Toolkit.” 2012. pp. 29-30.
http://library.ahima.org/PdfView?oid=105672.