You have the right to request to amend health information we maintain about you or your child if you believe the health information is inaccurate or incomplete. Please note, this does not include routine changes such as change of address or phone number. All of the following form fields below must be completed. If left blank, this could lead to delay in the processing of your request. If the patient is a minor, the legally authorized representative must complete this form. If the patient is an adult, they must complete the form themselves. No later than 60 days after you submit this completed form, you will receive a written response to your request via mail from Nationwide Children’s Hospital.
Patient First Name
Patient Last Name
Patient Date of Birth
Your Name
I am the Patient’s (check one):
Mother
Father
Self
Legal Guardian
Power of Attorney
Personal Representative
Other
If other, please specify
Your Mailing Address
City
State
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas US Virgin Islands Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip Code
Your Phone Number
Your Email
Driver’s license # or State ID #
Your preferred way to be contacted (this is how we will follow up with you on the outcome of your request)
MyChart
Postal Mail
Please specify 1 of the 2 fields so we can properly verify your identity:Insurance ID #
Outpatient Care Code
Please tell us what health information you would like us to amend. Be as specific as possible regarding the record type, where the record was generated, and the date. (For example, “I would like to amend my child’s ABC Laboratory test results dated December 5, 2010” or “all records reflecting my child’s blood type as O positive”)
Please tell us why you want the health information amended. Be as specific as possible about the reason. (For example, “My child never received a blood test from ABC Laboratory” or “my child’s blood type is O negative”)
Additional Comments
If the amendment is accepted, you may request that we notify others that you believe received the information in the past. By providing names below, you authorize Nationwide Children’s Hospital to notify them of the amendment.Name and/or Organization
Address
Phone
Fax
Digital Signature
By checking this box, I affirm that I am the patient’s representative and have the authority to authorize who may access this patient’s health information and to review and/or request changes to this patient’s health information.
If you have any questions or need additional support with your request, please contact the HIM department by phone at 614-355-0852, or by email at AmendmentRequests@nationwidechildrens.org
You have the right to request to amend health information we maintain about you or your child if you believe the health information is inaccurate or incomplete. Please note, this does not include routine changes such as change of address or phone number. All of the following form fields below must be completed. If left blank, this could lead to delay in the processing of your request. If the patient is a minor, the legally authorized representative must complete this form. If the patient is an adult, they must complete the form themselves. No later than 60 days after you submit this completed form, you will receive a written response to your request via mail from Nationwide Children’s Hospital.
Patient First Name
Patient Last Name
Patient Date of Birth
Your Name
I am the Patient’s (check one):
Mother
Father
Self
Legal Guardian
Power of Attorney
Personal Representative
Other
If other, please specify
Your Mailing Address
City
State
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas US Virgin Islands Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip Code
Your Phone Number
Your Email
Driver’s license # or State ID #
Your preferred way to be contacted (this is how we will follow up with you on the outcome of your request)
MyChart
Postal Mail
Please specify 1 of the 2 fields so we can properly verify your identity:Insurance ID #
Outpatient Care Code
Please tell us what health information you would like us to amend. Be as specific as possible regarding the record type, where the record was generated, and the date. (For example, “I would like to amend my child’s ABC Laboratory test results dated December 5, 2010” or “all records reflecting my child’s blood type as O positive”)
Please tell us why you want the health information amended. Be as specific as possible about the reason. (For example, “My child never received a blood test from ABC Laboratory” or “my child’s blood type is O negative”)
Additional Comments
If the amendment is accepted, you may request that we notify others that you believe received the information in the past. By providing names below, you authorize Nationwide Children’s Hospital to notify them of the amendment.Name and/or Organization
Address
Phone
Fax
Digital Signature
By checking this box, I affirm that I am the patient’s representative and have the authority to authorize who may access this patient’s health information and to review and/or request changes to this patient’s health information.
If you have any questions or need additional support with your request, please contact the HIM department by phone at 614-355-0852, or by email at AmendmentRequests@nationwidechildrens.org
You have the right to request to amend health information we maintain about you or your child if you believe the health information is inaccurate or incomplete. Please note, this does not include routine changes such as change of address or phone number. All of the following form fields below must be completed. If left blank, this could lead to delay in the processing of your request. If the patient is a minor, the legally authorized representative must complete this form. If the patient is an adult, they must complete the form themselves. No later than 60 days after you submit this completed form, you will receive a written response to your request via mail from Nationwide Children’s Hospital.
You have the right to request to amend health information we maintain about you or your child if you believe the health information is inaccurate or incomplete. Please note, this does not include routine changes such as change of address or phone number.
All of the following form fields below must be completed. If left blank, this could lead to delay in the processing of your request. If the patient is a minor, the legally authorized representative must complete this form. If the patient is an adult, they must complete the form themselves.
No later than 60 days after you submit this completed form, you will receive a written response to your request via mail from Nationwide Children’s Hospital.
Patient First Name
Patient Last Name
Patient Date of Birth
Your Name
I am the Patient’s (check one):
Mother
Father
Self
Legal Guardian
Power of Attorney
Personal Representative
Other
If other, please specify
Your Mailing Address
City
State
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas US Virgin Islands Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip Code
Your Phone Number
Your Email
Driver’s license # or State ID #
Your preferred way to be contacted (this is how we will follow up with you on the outcome of your request)
MyChart
Postal Mail
Please specify 1 of the 2 fields so we can properly verify your identity:Insurance ID #
Outpatient Care Code
Please tell us what health information you would like us to amend. Be as specific as possible regarding the record type, where the record was generated, and the date. (For example, “I would like to amend my child’s ABC Laboratory test results dated December 5, 2010” or “all records reflecting my child’s blood type as O positive”)
Please tell us why you want the health information amended. Be as specific as possible about the reason. (For example, “My child never received a blood test from ABC Laboratory” or “my child’s blood type is O negative”)
Additional Comments
If the amendment is accepted, you may request that we notify others that you believe received the information in the past. By providing names below, you authorize Nationwide Children’s Hospital to notify them of the amendment.Name and/or Organization
Address
Phone
Fax
Digital Signature
By checking this box, I affirm that I am the patient’s representative and have the authority to authorize who may access this patient’s health information and to review and/or request changes to this patient’s health information.
If you have any questions or need additional support with your request, please contact the HIM department by phone at 614-355-0852, or by email at AmendmentRequests@nationwidechildrens.org
Patient First Name
Patient Last Name
Patient Date of Birth
Your Name
I am the Patient’s (check one):
Mother
Father
Self
Legal Guardian
Power of Attorney
Personal Representative
Other
If other, please specify
Your Mailing Address
City
State
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas US Virgin Islands Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip Code
Your Phone Number
Your Email
Driver’s license # or State ID #
Your preferred way to be contacted (this is how we will follow up with you on the outcome of your request)
MyChart
Postal Mail
Please specify 1 of the 2 fields so we can properly verify your identity:Insurance ID #
Outpatient Care Code
Please tell us what health information you would like us to amend. Be as specific as possible regarding the record type, where the record was generated, and the date. (For example, “I would like to amend my child’s ABC Laboratory test results dated December 5, 2010” or “all records reflecting my child’s blood type as O positive”)
Please tell us why you want the health information amended. Be as specific as possible about the reason. (For example, “My child never received a blood test from ABC Laboratory” or “my child’s blood type is O negative”)
Additional Comments
If the amendment is accepted, you may request that we notify others that you believe received the information in the past. By providing names below, you authorize Nationwide Children’s Hospital to notify them of the amendment.Name and/or Organization
Address
Phone
Fax
Digital Signature
By checking this box, I affirm that I am the patient’s representative and have the authority to authorize who may access this patient’s health information and to review and/or request changes to this patient’s health information.
If you have any questions or need additional support with your request, please contact the HIM department by phone at 614-355-0852, or by email at AmendmentRequests@nationwidechildrens.org
Please specify 1 of the 2 fields so we can properly verify your identity:
Please tell us what health information you would like us to amend. Be as specific as possible regarding the record type, where the record was generated, and the date. (For example, “I would like to amend my child’s ABC Laboratory test results dated December 5, 2010” or “all records reflecting my child’s blood type as O positive”)
Please tell us why you want the health information amended. Be as specific as possible about the reason. (For example, “My child never received a blood test from ABC Laboratory” or “my child’s blood type is O negative”)
If the amendment is accepted, you may request that we notify others that you believe received the information in the past. By providing names below, you authorize Nationwide Children’s Hospital to notify them of the amendment.
If you have any questions or need additional support with your request, please contact the HIM department by phone at 614-355-0852, or by email at AmendmentRequests@nationwidechildrens.org
