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Williams College Request for Amendment of PHI
 

Summary: Williams College
Request for Amendment of PHI
Date of Request: ____________________________
Name: ____________________________________
Social Security Number:
Address
Phone Number (H) (W)
I understand that the health plan may or may not supplement the medical record with an
addendum based on my request and under no circumstances is able to alter the original
documentation of the medical record. This request for an amendment by means of an
addendum may be made part of my permanent health plan record and will be sent to
individuals/organizations identified below as having relied on the content of my health plan
record.
Describe the information you want amended (e.g., claims records, health plan notes)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Date(s) of information to be amended (e.g., date of claim, date of treatment or other health care
service) _________________________________________________
What is your reason for making this request?

  

Source: Aalberts, Daniel P. - Department of Physics, Williams College

 

Collections: Physics