Request to amend protected health information (PHI)

Request to amend protected health information ( PHI ) Date of request : Patient Name : Date of birth : Mailing address Telephone number :

What PHI would you like changed ? Please include treatment dates and physician names if you know them .

Why would you like this PHI changed ?

Renown Health may deny your request to amend your PHI if :

• Renown did not produce the record

• The record has been reviewed and is considered accurate and complete

• You do not have the right to access the information you want changed

• The information you want changed is not used to make decisions about your care

Signature of patient : OR Signature of Personal Representative Relationship to patient :

( If patient is not a minor child , please include a power of attorney or other documentation demonstrating signer ’ s authority to request this on the patient ’ s behalf )

Please send completed form to : Renown Health Health Information Management 1155 Mill St , MS 012 Reno NV 89502

If you do not receive an acknowledgement letter regarding this request within 7 days , please call the number below or email statuscheck @ renown . org .

Form Number : 100-027 Revision Date : 5 / 2023