DSS Form 4005 "Request for Amendment of Protected Health Information" - South Carolina

What Is DSS Form 4005?

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

Form Details:

  • Released on April 1, 2003;
  • The latest edition provided by the South Carolina Department of Social Services;
  • 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 DSS Form 4005 by clicking the link below or browse more documents and templates provided by the South Carolina Department of Social Services.

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Download DSS Form 4005 "Request for Amendment of Protected Health Information" - South Carolina

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South Carolina Department of Social Services
REQUEST FOR AMENDMENT OF PROTECTED HEALTH INFORMATION
Name:
Date of Birth:
Address:
Telephone:
NOTICE: Individuals may seek to amend their protected health information (PHI) in their client files. The original
information in the file will not be erased or obliterated as a result of this amendment if approved.
Date of record:
I believe my records should be amended as follows:
My reason for amending my record is:
I request that the following person(s) be notified of the amendments to my protected health information.
Signature of Individual or Representative
Date
Printed Name
Relationship to Client
DSS Form 4005 (APR 03)
South Carolina Department of Social Services
REQUEST FOR AMENDMENT OF PROTECTED HEALTH INFORMATION
Name:
Date of Birth:
Address:
Telephone:
NOTICE: Individuals may seek to amend their protected health information (PHI) in their client files. The original
information in the file will not be erased or obliterated as a result of this amendment if approved.
Date of record:
I believe my records should be amended as follows:
My reason for amending my record is:
I request that the following person(s) be notified of the amendments to my protected health information.
Signature of Individual or Representative
Date
Printed Name
Relationship to Client
DSS Form 4005 (APR 03)