Request for Medical Record Correction/Amendment Form

Date(Required)

Patient Name(Required)

First Last

UA Little Rock T#(Required)

Date of Birth(Required)

Patient Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Date of entry to be Corrected/Amended(Required)

Information to be Corrected/Amended(Required)

Please explain how the entry is incorrect or incomplete. What should the entry say to be more accurate or complete?(Required)

If you agree, Health Services will make a reasonable effort to provide the amendment to other persons and/or entities who Health Services knows received this information in the past and who may have relied, or are likely to rely, on such information in a manner that may be detrimental to your health care. Would you like this amendment sent to anyone else who received the information in the past?(Required)

Yes

Name of individual or entity to whom we are sending the information

Address of individual or entity where we are sending the information

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Electronic Signature(Required)

Electronic signatures are valid, legal and binding in the United States.

Health Services has the right to deny or partially deny your request for an amendment if you ask us to amend information that we did not create, is not part of the health information we keep, you would not be permitted to inspect and copy, or if our information is accurate and complete. If we deny your request, you have the right to file a rebuttal and request that the rebuttal be made part of your medical record.

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Request for Medical Record Correction/Amendment Form

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CampusWell