The Arc of Monroe County, NYSARC, Inc
REQUEST BY A PERSON SERVED FOR AMENDMENT OF RECORDS You have the right to request that The Arc amend most information in our records that may be used to make decisions about you or your treatment for as long as we maintain the information in our records. Please refer to our Notice of Privacy Practices for a more detailed description of your rights to request amendment of this information and the process we follow once we have received such a request. To request an amendment to your records, please complete and return the following request form. Name of person served: ____________________________________________________ Last First MI Address: ________________________________________________________________ Telephone: __________________________ (day)
_________________________ (eve)
E-mail address: ___________________________________________________________ Amendment Request: Please answer the following questions. You may attach a separate page if more space is needed. 1. What information would you like to amend? ________________________________ ________________________________________________________________________ ________________________________________________________________________ 2. How do you believe the information should be amended? ______________________ ________________________________________________________________________ ________________________________________________________________________ 3. Why do you believe the information should be amended? Your request may be denied if you do not provide a reason to support your request. ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________
Amendment of PHI forms
The Arc of Monroe County, NYSARC, Inc
If this request is being made because of an emergency, please indicate below the nature of the emergency or urgency and the date you need the information amended. We cannot guarantee that we will meet your deadline, but we will do our best to accommodate reasonable requests. ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________
______________________________________________ Printed name of person served or personal representative
__________________ Date
______________________________________________ Signature of person served or personal representative
__________________ Date
______________________________________________ Description of personal representatives authority
__________________ Date
Please send completed form to: Privacy Officer The Arc of Monroe County 1000 Elmwood Ave Suite 500 Rochester, NY 14620
For Arc of Monroe County Use Only: Date received: _____/_____/_____ Disposition of request: _____ Granted; _____ Denied; _____ Partially Denied Person served notified in writing of response to request on this date: _____/_____/_____ Name of staff person processing this request: __________________________________
Amendment of PHI forms
The Arc of Monroe County, NYSARC, Inc
Letter indicating that the agency cannot respond within 60 days [Date] [Name] [Address] [City, State, Zip]
Re: Request for amendment of protected health information
Dear [Name]: This letter responds to your request that we amend your protected health information, which we received from you on __________________. We have been working hard to determine whether we can grant your request. We are usually able to process requests for amendment of records within 60 days. However, for the following reason, we need an additional 30 days to respond to your request: We are still working to access the information that you would like amended. We are still preparing the amendment you requested. We are working to verify whether the information is inaccurate and incomplete without the amendment you requested. We need more time because _________________________________________________ We expect to have an answer for you no later than ____________________________________. If we need additional time, we will contact you again. Please contact the Privacy Officer at (585) 271-0660 if you have any concerns about this delay. Thank you. Sincerely,
[person sending letter]
Amendment of PHI forms
The Arc of Monroe County, NYSARC, Inc
Letter agreeing to the request to amend PHI
[Date] [Name] [Address] [City, State, Zip]
Re: Request for amendment of protected health information
Dear [Name]: This letter responds to your request that we amend your protected health information, which we received from you on ______________________. We agree to make the amendment that you have requested. Your records will be updated accordingly. If you agree, we will also notify other persons or organizations about this amendment that may rely on the original (un-amended) information they currently have in a way that may negatively affect you. In addition, we will notify other persons or organizations that you identify that may have the original (un-amended) information. Please contact the privacy officer at (585) 271-0660 if you would like us to notify these other parties for you. As always, we are committed to helping you assure that information about you is kept accurate. Thank you for your assistance and patience in helping us to achieve this goal. Sincerely,
[person sending letter]
Amendment of PHI forms
The Arc of Monroe County, NYSARC, Inc
Letter denying the request for amendment of PHI
[Date] [Name] [Address] [City, State, Zip]
Re: Request for amendment of protected health information
Dear [Name]: This letter responds to your request that we amend your health information, which we received from you on ______________________. For the reasons state below, we are denying your request: Your request was not in writing. Your request did not explain why you believe we should make the amendment. The information you would like to have amended is not available in records that we use to make decisions about you or your treatment. The information you would like to have amended was not created by our agency. You may wish to ask the person or organization that created the information for an amendment. The information you requested cannot be amended because you are not entitled to inspect this information. The reason you are not entitled to inspect the information is _______________________________________________________________________. We believe that the information is accurate and complete without the amendment you have requested. You have the right to submit a statement explaining your disagreement with our decision to deny the amendment you requested. This statement must be in writing and should be no longer than 2 single-sided pages (typed or written). We will include you statement, or an accurate summary of it, any time we disclose to others the protected health information that you think should have been amended. However, we reserved the right to prepare a response to your statement of disagreement (called a “rebuttal statement”), which we may also include when we make future disclosures of the information that you think should have been amended. If you wish to exercise this right, please send your statement of disagreement to The Arc’s privacy officer c/o The Arc of Monroe County, 1000 Elmwood Ave Suite 500, Rochester, NY 14620. If you do not submit a statement of disagreement, we will include only your amendment request and this denial notice in any future disclosures of the information which you think we should have amended. Amendment of PHI forms
The Arc of Monroe County, NYSARC, Inc
We hope that you understand the reason that we have denied the amendment you requested. However, if you believe that we have improperly handled your request, you may file a complaint with us or with the Secretary of the Department of Health and Human Services. No one can retaliate against you for filing a complaint. Thank you. Sincerely,
[person sending letter]
Amendment of PHI forms
