Request for Amendment of Health Information Form

Name
Date of Birth

MonthDayYear
Date
Social Security Number
Phone Number
Address
Medical Record Number
Account Number
Date of Entry to be Amended

MonthDayYear
Date
Type of Entry to be Amended
Facility

Cape Fear Valley Medical CenterCape Fear Valley Rehabilitation CenterBehavioral Health CareHighsmith-Rainey Specialty HospitalBladen HealthcareHoke HospitalOther
What is the reason for the amendment
What should the amended documentation be
Would you like this amendment sent to anyone to whom we may have disclosed the information in the past?

YesNo
If yes, please specify the name and address of the organization or individual.
Name
Address
Name
Address
Signature of Patient or Legal Representative

Clear
Date

MonthDayYear
Date
This request for amendment of health information will be responded to within sixty days (60) of receipt of the request. An extension of thirty days (30) may be allowed, if needed, to process this request for amendment. If an extension is required, you will be notified in writing of the reason for the extension and the date by which the amendment will be processed. Thank you.
Should be Empty: