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.
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