Request To Amend Protected Health Information Form

Request to Amend Protected Health Information
Request Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
- Patient Name
  
  First NameMiddle NameLast Name
- Date of Birth
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Patient Representative (Power of Attorney or Legal Guardian)
  
  First NameMiddle NameLast Name
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Phone Number
  Format: (000) 000-0000.
- Email Address
- Information to be changed:
- Reason for change:
- Notice for changes:
- If your request is denied you may:
  - Submit a statement to Corstrata disagreeing with the denial
  - Request that your original amendment request and/or your disagreement with the denial be attached to future disclosures of your PHI
  - File a complaint with Corstrata or the U.S. Department of Health and Human Services
- Print Full Name
- Completed/Signed by:
- Signature
- Please attach a copy of your government-issued ID. If signed by Patient Representative, provide relationship to the patient and proof of Legal Representation
  
  Cancelof
- Corstrata, Inc.
  Privacy Officer
  P.O. Box 30643
  Savannah, GA 31410
  Phone #: (800) 566-1307
  Fax #: (855) 236-5024
  Email: Privacy@Corstrata.com
- Should be Empty: