REQUEST TO AMEND PROTECTED HEALTH INFORMATION
Acclaim Autism, 2929 Arch St, Suite 1700 Philadelphia PA 19104
Parent / Guardian Name:
*
First Name
Last Name
Parent / Guardian E-mail:
*
Phone Number
*
-
Area Code
Phone Number
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patient Name
*
First Name
Last Name
Patient Date of Birth
*
-
Month
-
Day
Year
Date
Record(s) to be Corrected:
Date(s) of Entry to be Corrected/Amended
*
Information to be Corrected / Amended (please be as specific as possible)
*
Please state as precisely as possible how you would like the see the record worded:
*
Provide reason for request of correction / amendment:
*
Authorization
*
I hereby authorize Acclaim Autism its agents and its employees to update protected health information described above. I confirm I am legally authorized to consent for this patient's healthcare. I understand this is a request and the request will receive a response within 30 days, whether the request is approved or not. I further understand I may submit this request through a paper form by mail or fax if I do not wish to use the digital version.
Signature
*
Submit
This form is HIPAA-compliant.
Should be Empty: