Danville Fire Department
Request for Amendment of phi
Danville Fire Department and Center Township / Danville
Ambulance Service
Request for Amendment of Protected Health Information
Patient Name: __________________________________________________________
Address: ______________________________________________________________
City: _________________________ State: ________ Zip Code:
Information to Amend:
Please check the field that represents the type of information you would like to amend.
____ Name ____ Marital Status
____ Billing Address ____ Surrogate Decision Maker
____ Mailing Address ____ Organ Donor
____ Current Medical Condition ____ Other: Please describe
____ Past Medical History ___________________________
____ Current Medications ___________________________
____ Allergies ___________________________
Please specifically describe what information you wanted amended. Please ONLY list the new information. Attach a separate sheet if necessary.
Danville Fire Department and Center Township / Danville Ambulance Service, in its capacity as a health care provider, is entitled to perform and bill for services based on all protected health information in its current form or upon which it has already relied until such time as the amended information becomes effective. Danville Fire Department and Center Township / Danville Ambulance Service is not required to accept your request for amendment and will notify you in writing as to the decision on your request.
Your signature below indicates that you have agreed to accept these terms as they have been listed and to provide payment, if required, to Danville Fire Department and Center Township / Danville Ambulance Service based on existing protected information until such time that the amendments you have made are effective.
Patient Signature: ____________________________________ Date: ___________
[NOTE: Generally, you must respond to requests for amendments to PHI within 60 days of your receipt of the amendment request. If you are unable to respond to the request within 60 days, you may extend your decision period for an additional 30 days, provided that you furnish a written notice to the requester, explaining the reasons for the delay and the date by which you will take action on the request]