Managing Amendments in an HIE Environment. Appendix C AHIMA Sample Patient Statement of Disagreement

Patient Name:_______________________________________________________________________

Date of Birth:________________________________________________________________________

Address: ____________________________________________________________________________

City:_____________________________________ State:_______________ Zip Code: ______________

Home Phone: (_______)____________________ Work Phone: (_______)________________________ 

Statement of Disagreement:



You may request that [insert name of organization] provides your request for amendment and the denial with any future request for information.

If you want more information about our privacy practices, have questions or concerns, or believe that we may have violated your privacy rights, please contact: [Insert name, address and phone number of organization]

You also may submit a written complaint to the US Department of Health and Human Services. We will provide you with the address upon request. We support your right to protect the privacy of your medical information. We will not retaliate in any way if you choose to file a complaint.