Medical Records Amendment Request
Thank you for contacting the Medical Records Department of East Alabama Health. We are here to serve you and your health care needs.
Below you will find a Request for Amendment of Protected Health Information form. Please make sure you include specific instructions as to what record needs to be corrected. Include the date of service, the section of record the incorrect information is on, and the actual incorrect wording and what the record should say.
Example of health information to be amended
On the History and Physical section of my visit from November 25th, 2009, it states I "arrived at the hospital via private vehicle." This is incorrect, I arrived at the hospital via ambulance. Please correct.
Example of detailed explanation for requested amendment
My insurance company is denying the claim for the ambulance service because the record is showing I arrived in private vehicle and not an ambulance. I can provide you with the ambulance invoice showing the date of service and the route the ambulance service took to bring me to your hospital if needed. Thank you.
Please feel free to contact our legal department with any questions you may have about the form or process. You may reach our legal department at 334-528-3279.
Medical Records Amendment Request
I understand that I have the right to request an amendment of my health information, maintained by or for East Alabama Medical Center, and that East Alabama Medical Center may deny my request if it determines that I have asked to amend information that: was not created by East Alabama Medical Center, unless the person or entity that created the information is no longer available; is not health information maintained as part of a designated record set; is information that I am not permitted to inspect or copy; or East Alabama Medical Center determines that the information is accurate and complete. If East Alabama Medical Center disagrees with my requested amendment, it will provide me with a written explanation of the reasons for the denial, an opportunity to submit a statement of disagreement, and a description of how I may file a complaint.
I hereby request that East Alabama Medical Center amend my health information in the following manner and for the following reasons: