Saint Therese Home, Inc

8000 Bass Lake Road

New Hope, MN 55428

 

RESIDENT REQUEST TO AMEND PROTECTED HEALTH INFORMATION

 

Resident Name _________________________          Medical Record #_____________________

 

Other Name(s) ______________ DOB ______          Social Security #______________________

 

I request the opportunity to amend my personal health information maintained by St. Therese as described below.

 

Please fill out the information requested below completely.

 

I would like the following information to be amended:

____________________________________________________________________________________________________________________________________________________________

 

I would like the information to be amended in the following manner:

____________________________________________________________________________________________________________________________________________________________

 

I believe the amendment is necessary for the following reasons:___________________________

______________________________________________________________________________

 

I understand that St. Therese may deny my request for an amendment if it is not in writing or does not include a reason to support the request.  In addition, St. Therese may deny my request if the information:

 

  1. Was not created by the facility, unless I provide reasonable evidence that the person or entity that created the information is no longer available to act on the requested amendment;
  2. Is not part of my clinical or billing records maintained by or for the facility or used to make decisions about me;
  3. Is not part of the information that I have a right to inspect and copy; or
  4. Is already accurate and complete as determined by the facility.

Please allow staff three days to complete request

 

 

___________________________________              ____________________________________

Signature of Resident/Responsible Party                         Relationship to Resident if Signed by Res. Party

 

______________________________________                    _______________________________________

Date of Resident’s/Responsible Party’s Signature           Reason Resident Unable to Sign