The federal Health Insurance Portability and Accountability Act (HIPAA) of 2000 mandates that patient's have the right to request changes in their protected health care information. Technically, HIPAA does NOT apply to David A. Edwards, MD, HMD or Bio Health Center since neither qualifies under the law as a "covered entity." However, Dr. Edwards agrees with the right to request necessary corrections in private health information and voluntarily complies with HIPAA, despite his non-covered status under the law. The law states HIPAA "covered entities" have 60 days to respond to requests for changes or amendments to private medical records and that such requests may be required to be "in writing." If you wish to have your private medical record created by Dr. Edwards and/or Bio Health Center corrected or amended please complete and return the following information (please PRINT):
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Name:  |
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Address:: |
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Birthdate: |
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Social Security Number: |
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Please explain the information you wish to be changed or corrected:
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Please list the reason(s) for the request and any suggested language you would like used: |
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Please provide the name(s), address(es) and phone number(s) of any
and all other "entities" you wish to inform of the corrected
record information you wish: |
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Signature:
Date of Request: Please be aware that a legal denial for this request is allowed under federal law if: 1) the information on file is correct as recorded, 2) another federal law prohibits releasing your information to you, 3) the information correction being requested is not part of our records or 4) our office did not create the original record you wish to correct or amend.
Reason(s) for denial of request:
