Medical Record Amendment Policy

    Patient may request that his/her medical recorded be changed, corrected, or amended. This request must be in writing and must include the reason for the desired change, amendment, or correction.

    This practice may accept or deny this request and will inform the patient in writing of the decision within 60 days. One 30-day extension is permitted if the patient is notified of the reason for the delay. If the request is denied, the practice must give a reason for denying the request.

    Requests will be retained for six (6) years and must be included in future releases of the patientís protected health information (PHI). If the amendment request has been denied, this denial letter must also be included in future PHI disclosures.

    Requests for amendment of medical records should be submitted to Dr. Elliott for action.

Medical Record Amendment Request Form

I, _________________________________, request that Brett Elliott, M.D. P.A.

change/amend my medical record because:

(Explain what is to be changed/amended and why.)

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For my medical record to be more complete/accurate, it should say:

__________________________________________________________________________________________________________________________

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Patient signature: ________________________________________________ Date of request: ______________

Practice Response:

Accept change _____

Deny change with explanation:

__________________________________________________________________________________________________________________________

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Signature of physician: _________________________________________  Date:______

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This page was last updated on 07/26/2013