Valdosta State University

Request for Correction/Amendment of Protected Health Information

* Speech Clinic

* Student Health Services

* Athletic Department

* Human Resources

* Other. Please Specify ___________________________________________

Patient/Employee Name:________________________         Date of Birth:_________________________

Patient/Employee Address:

________________________________

                           Street

________________________________

                           Apartment #

________________________________

                           City, State Zip

Type of Entry to be Amended:____________________________________________________________

Please explain how the entry is inaccurate or incomplete.

_____________________________________________________________________________________

_____________________________________________________________________________________

Please specify what the entry should say to be more accurate or complete.

_____________________________________________________________________________________

_____________________________________________________________________________________

_________________________________________                           _____________________________

Signature of Patient/Employee or Legal Guardian                        Date

FOR INTERNAL PURPOSES ONLY:

Date Request Received:____________

Amendment has been:       Accepted

                                                Denied

                                       Denied in part, Accepted in part

If denied (in whole or in part)*, check reason for denial:

PHI was not created by this organization.

PHI is not available to the Patient/Employee for inspection in accordance with the law.

PHI is not a part of Patient/Employee's designated record set.

PHI is accurate and complete.

Comments from healthcare provider who provided service:

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Name of Staff Member Completing Form: ______________________________

Title:     __________________________________

____________________________________________                       _____________________________

Signature of Healthcare Provider Who Provided Service                    Date

*If your request has been denied, in whole or in part, you have the right to submit a written statement disagreeing with the denial to Valdosta State University, Attn: {Privacy Officer, Department of Human Resources, 1500 North Patterson St., Valdosta, GA 31698 }. If you do not provide us with a statement of disagreement, you may request that we provide to you copies of your original request for amendment, our denial, and any disclosures of the protected health information that is the subject of the requested amendment. Additionally, you may file a complaint with the Secretary of the U.S. Department of Health & Human Services.

*Valdosta State University must inform Patient/Employee that a written request is required, and that the Patient/Employee is required to provide a reason to support the requested change.