The Counseling Center

of Wayne and Holmes Counties

 

Est. 1953 ~ Over 55 years of service excellence!

 

 

Request for Amendment to Health Information

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SECTION A:        Client to complete the following information.

NAME:_______________________________________________  BIRTH DATE:____________________

 

ADDRESS:____________________________________________________________________________

 

TELEPHONE:__________________________________________  DATE:_________________________

  

REQUEST:

 

I hereby request The Counseling Center to amend the following (check all that apply):

 

____ My medical records            

       

____ My billing records

 

____ Other: Please describe __________________________________________________________

 

Date(s) of information to be amended (e.g. date of visit, treatment, or other health care services)        From: _________________________ To: ____________________________

The information is incorrect or incomplete in the following manner: 

 

______________________________________________________________________________________

 

______________________________________________________________________________________

 

______________________________________________________________________________________

 

I request this amendment for the following reason(s): ________________________________________

 

______________________________________________________________________________________

 

______________________________________________________________________________________

 

The information should be amended as follows: _____________________________________________

 

______________________________________________________________________________________

 

______________________________________________________________________________________

I would like this amendment sent to the following persons who may have received my health information in the past (please specify name and address of the individuals or organizations):

 

Name _________________________________

Address _______________________________

City/State/Zip __________________________

 

Name _________________________________

Address _______________________________

City/State/Zip __________________________

Name _________________________________

Address _______________________________

City/State/Zip _________________________

 

Name _________________________________

Address _______________________________

City/State/Zip __________________________

       

I understand that The Counseling Center may or may not supplement the medical record with an addendum based on my request.  I also understand that The Counseling Center is not able to alter the original documentation in the medical record under any circumstances.  I understand that this request will be made a part of my permanent medical record and will be sent as part of the medical record.

 

Signature_____________________________________________   Date ________________ 

Signature of Parent or Guardian___________________________    Date _________________

 

 

 

 

SECTION B:  The Counseling Center to complete the following.

 

DATE OF RECEIPT OF REQUEST _______________________________

 

Request for correction / amendment has been:     ____ Accepted              ____ Denied

 

If denied, check reason for denial:

 

____ The Protected Health Information was not created by this agency.

____ The Protected Health Information is not part of client’s designated record set.

____ The Protected Health Information is not allowed to be disclosed.

____ The Protected Health Information is accurate and complete.

 

Comments:

 

 

 

NOTIFICATION

 

The client and/or others have been notified of determination via one or more of the following (check all that apply):

 

____ Notice of Acceptance of Amendment sent to client on this date: ______________________.

____ Notice of Denial of Amendment sent to client on this date: ___________________________.

____Notice of Acceptance of Amendment sent to identified persons pursuant to client authorization on this date:________________________________________________________.

 

 

        _______________________________________________        _____________________

        Diane S. DeRue, MPA, LSW                                                Date

        Compliance and Privacy Officer

 

Directions for printing the HIPAA forms.

 

Click on the Print button in the task bar of your Internet browser. If your print button does not work please us the following steps.

 

Step 1.  Right click on the mouse and in the menu that appears, left click on the "Select All" option.   

Step 2. When the text is highlighted, right click on the mouse once again and in the menu that  appears, left click on the "Copy" option.

Step 3. Right click on the mouse and in the menu that appears, left click on the "Print" option.

 

Forms to request changes, corrections and/or copies of your clinical record are also available from the Corporate Compliance and Privacy Officer, Medical Records or any Counseling Center office.