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| Form Title: | HIPAA Request for Amendment Form |
| Last Revised: | 4/2003 |
| Purpose: | As required by the Health Information Portability and Accountability Act of 1996 (HIPAA) you have a right to request that health information that pertains to you be amended if you believe that it is incorrect or incomplete. We will review your request and either grant your request or explain the reason why it will not be granted. In the event that your request is not granted, you have the right to submit a statement of disagreement that will accompany the information in question for all future disclosures. |
| Who Should Use the Form: | Employee and Contact Person |
| Instructions: | The employee completes the Request for Amendment Form (first tab), signs and submits to Laurie Carr (confidential internal mail to CG4 or fax 303-497-8701). |
| View the Form: | View a Blank Tab 1 Form in .pdf Format | Blank Tab 2 | Blank Tab 3 | Blank Tab 4 |
| Form Download Information | |
| File Format: | Excel 5.0 (.xls) |
| Download File: | Click Here to Download the Form! |
| Problems? Contact: | Laurie Carr, x8702 |
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