Request for Amendment of Health Information Form Logo
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  • If yes, please specify the name and address of the organization or individual.

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  • 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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