Family MedCenters, P.A.
Response to Request for Amendment
Patient Name / Birth Date / Social Security NumberFamily MedCenters has reviewed your Request for Amendment of Protected Health Information and has made the following determination with respect thereto:
q We have granted the Request for Amendment of Protected Health Information. We will make all the corrections to the affected records and will make reasonable efforts to inform our business associates and others that have received the information of the amendment so they will have the correction. Within ten (10) days of receipt of this Response to Request for Amendment, you must provide us with a list of persons who received the original record and with whom the amendment needs to be shared. This information should be sent to Family MedCenters, Attention Privacy Official, 1101 North Rock Road, Derby, Kansas 67037.
q We have reviewed your Request for Amendment and denied it because:
q The record is complete and accurate.
q The information was not created by Family MedCenters.
q The information is not part of the designated record set.
q Other ______
You have the right to file a written statement disagreeing with our denial of your request by sending it to Family MedCenters, Attention Privacy Official, 1101 North Rock Road, Derby, Kansas 67037. If you file a statement of disagreement, we will prepare a rebuttal statement, add it to the disputed record, and provide you with a copy. If you submit a statement of disagreement, the Request for Amendment of Protected Health Information, the Response to the Request for Amendment, the statement of disagreement, and the rebuttal statement will become part of your designated record set and will be included in future disclosures of the record.
If you do not submit a statement of disagreement, you may request that we include your Request for Amendment of Protected Health Information and our Response to Request for Amendment with future disclosures of the relevant record. You should note that we will include such documents with future disclosures only if you affirmatively request that they be included.
q Please check here if you do not wish to submit a written statement of disagreement, but do wish to have your Request for Amendment of Protected Health Information and our Response to Request for Amendment included in future disclosures and send a copy of this form back to Family MedCenters, Attention Privacy Official, 1101 North Rock Road, Derby, Kansas 67037.
If you wish to file a complaint about our denial, you can file a written complaint with Family MedCenters by mailing it to Family MedCenters, Attention Privacy Official, 1101 North Rock Road, Derby, Kansas 67037 or by calling us at 316-788-6963. Family MedCenters will review the complaint and inform you of the resolution.
You also have the right to file a complaint with the Secretary of the Department of Health and Human Services. Send your written complaint within 180 days of this denial to: Medical Privacy, Complaint Division, Office for Civil Rights, United States Department of Health and Human Services, 200 Independence Avenue, SW, Room 509F, HHH Building, Washington DC, 20201.