Request for Medical Record Correction/Amendment Form

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Patient Name(Required)
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Patient Address(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)
Address of individual or entity where we are sending the information
Electronic signatures are valid, legal and binding in the United States.
This field is for validation purposes and should be left unchanged.