Form C "Request to Amend or Limit Protected Health Information" - Alabama

What Is Form C?

This is a legal form that was released by the Alabama Department of Public Health - a government authority operating within Alabama. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • The latest edition provided by the Alabama Department of Public Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form C by clicking the link below or browse more documents and templates provided by the Alabama Department of Public Health.

ADVERTISEMENT
ADVERTISEMENT

Download Form C "Request to Amend or Limit Protected Health Information" - Alabama

Download PDF

Fill PDF online

Rate (4.7 / 5) 24 votes
FORM C
REQUEST TO AMEND OR LIMIT
PROTECTED HEALTH INFORMATION
Patient Name: ________________________________ Date of Birth: ______________
Address where you want the amendment response sent:
_________________________________________________________________
NOTICE TO PATIENT: Your request to amend or limit your protected health information
(such as health records, name, address, and social security number), in any form only applies to
the information maintained by the Alabama Department of Public Health (hereinafter “ADPH”).
If you would like to request amendments or limits to your protected health information
maintained by any other Health Care Provider, a separate request must be submitted to that
provider.
REQUESTED AMENDMENT:
I request that ADPH amend or limit (describe the information you would like amended or
restricted):
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
I request the amendment or limitations described above to be made to the protected health
information in my designated record set (medical record) maintained or created by ADPH.
Date of record or information you would like to amend or limit:
__________________________
I would like this information amended or limited because (state specific reason for request):
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
FOR AMENDMENTS: I am attaching proof that my record should be amended because it is
false, inaccurate or incomplete.
PLEASE NOTE: No form will be considered unless you provide sufficient proof that the
record that you intend to be amended is false, inaccurate, or incomplete. [An example of an
appropriate attachment would be your birth certificate to prove that the date of birth in your file
is wrong]
__________________________________________
_________________
*
[Signature/Title, if legal representative
]
Date
*May be requested to submit evidence of representative status.
FORM C
REQUEST TO AMEND OR LIMIT
PROTECTED HEALTH INFORMATION
Patient Name: ________________________________ Date of Birth: ______________
Address where you want the amendment response sent:
_________________________________________________________________
NOTICE TO PATIENT: Your request to amend or limit your protected health information
(such as health records, name, address, and social security number), in any form only applies to
the information maintained by the Alabama Department of Public Health (hereinafter “ADPH”).
If you would like to request amendments or limits to your protected health information
maintained by any other Health Care Provider, a separate request must be submitted to that
provider.
REQUESTED AMENDMENT:
I request that ADPH amend or limit (describe the information you would like amended or
restricted):
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
I request the amendment or limitations described above to be made to the protected health
information in my designated record set (medical record) maintained or created by ADPH.
Date of record or information you would like to amend or limit:
__________________________
I would like this information amended or limited because (state specific reason for request):
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
FOR AMENDMENTS: I am attaching proof that my record should be amended because it is
false, inaccurate or incomplete.
PLEASE NOTE: No form will be considered unless you provide sufficient proof that the
record that you intend to be amended is false, inaccurate, or incomplete. [An example of an
appropriate attachment would be your birth certificate to prove that the date of birth in your file
is wrong]
__________________________________________
_________________
*
[Signature/Title, if legal representative
]
Date
*May be requested to submit evidence of representative status.
REQUEST APPROVED:
If ADPH approves your request to amend or limit the release of your record, please complete the
attached form (FORM D), and return it to us, to identify any persons or entities that we need to
notify of the amendment or limitation to your protected health information.
REQUEST DENIED:
By: ____________________________________________________________________
Signature
Title
Date
Reason for Denial:
○ The information was not created by ADPH.
○The information is not part of your Designated Record Set.
○ The information is not available for your inspection pursuant to the ADPH’s
Policy regarding individual access because _____________________________________
_______________________________________________________________________.
○ The information is accurate and complete.
If your request for an amendment or limitation to your protected health information is denied,
you may submit a written statement of your disagreement with the denial. Send the statement of
disagreement to:
Privacy Officer
Alabama Department of Public Health
201 Monroe Street, Suite 785
Montgomery, AL 36104
(334) 206-2648
After submitting your disagreement in writing, you will be given an opportunity for a hearing on
why your request was denied. You will receive sufficient notice of the time and place that the
hearing will be held.
*********************Retain for minimum of 6 years********************
Page of 2