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Request for Amendment of Protected Health Information

Request for Amendment of Protected Health Information

Name
Address

Note:  any requested changes regarding Date of Birth or Address, will require appropriate documentation to support.
I understand that Inspira Health may or may not approve this request.  


I further understand Inspira Health will notify me whether my request is granted or denied, within sixty (60) days of receiving this request.  If Inspira Health is unable to comply with my request within this timeframe, I understand that it may extend to applicable deadline for up to an additional thirty (30) days by notifying me in writing.
 

Relationship to the patient:

If you are NOT the patient but are signing on behalf of the patient, this information is required:

Address

Relationship to the patient:

I am the (check which applies)

A member of our compliance team will contact you to obtain proof of your authority to act on behalf of the patient as checked above (other than parent).

 

***If this is an emergency or you are experiencing chest pain, shortness of breath, or an allergic reaction, please call 911 or report to your closest Emergency Room immediately. Do not use this form for urgent medical needs.

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