Request for Amendment of Health Record

For use by Department of Human Services (DHS) and Oregon Health Authority (OHA) clients asking for amendment of their health records.

Name: (print) / ID number: (case, prime, reservation number or SSN)
Client’s mailing address:
Record holder: (office, district) / Date of birth:
Location of record: (address) / Date of request:

Submit this request to the office where services were received.

If you are requesting an amendment to the Department of Human Services (DHS) or the Oregon Health Authority (OHA) record of your health information, please consider:

·  DHS and OHA cannot amend records that DHS or OHA did not create.

·  DHS and OHA will only amend records if they are found to be incomplete or inaccurate.

·  Please attach any information you have to support your request.

I am asking for the following amendment to the record of my health information (be specific):

Full legal signature of individual or authorized personal representative:
/
Date:
Personal representative authentication: /
Relationship to client:
DHS or OHA staff only Approved Denied Delayed
If delayed we will act on your request by:
Reason for delay or denial:
DHS or OHA representative signature / Date

Your right to request to amend information in your record:

·  You have a right to request amendments to your information held in DHS or OHA files.

·  You have a right to have an answer to your request within 60 days. If there are delays in getting you the answer, you will be notified in writing and this delay cannot be more than an additional 30 days.

·  If you disagree with the answer, you can provide a written statement saying how you would like your record to be changed. DHS or OHA will keep this statement with your record.

·  DHS or OHA may also write an answer to your statement, which will also be placed in your record. You can have a copy of this.

·  Anytime your record is amended, both your statement and DHS or OHA answer will be included, when relevant.

You have a right to file a complaint if you disagree with the decision.

Complaints may be directed to any of the following:

State of Oregon Department of Human Services

Governor’s Advocacy Office 500 Summer St. NE, E17 Salem, Oregon 97301-1097
Phone: 1-800-442-5238, FAX: 503-378-6532, Email:

Oregon Health Authority, Privacy Officer

500 Summer Street NE, E24, Salem, OR 97301

Phone: 503-945-5780, FAX: 503-947-5396, Email:

U.S. Department of Health and Human Services, Office for Civil Rights
(for health information only)

Medical Privacy, Complaint Division 200 Independence Avenue, SW HHH Building, Room 509H, Washington, D.C. 20201
Phone: 866-627-7748, TTY: 886-788-4989, Email:

For current or former patients of the Oregon State Hospital (OSH) or Blue Mountain Recovery Center (BMRC):

OSH – Director of Consumer and Family Services
2600 Center St. NE, Salem, OR 97301
Phone: 503-945-7132 / BMRC – Superintendent
2600 Westgate, Pendleton, OR 97801
Phone: 541-276-0810 Extension: 236
This document can be provided upon request in alternative formats for individuals with disabilities or in a language other than English for people with limited English skills. To request this form in another format or language, contact your local office. For a list of local offices please see www.oregon.gov/DHS/localoffices/index.shtml.

Page 2 of 2 MSC 2094 (11/11)