Request to Correct Personal Health Information

  • PART 1 - PATIENT / CLIENT INFORMATION

  • PART 2 - I REQUEST THE FOLLOWING CORRECTION

    If NO - complete Part 3
  • PART 3 - PERSONS PERMITTED TO EXERCISE THE RIGHTS OF AN INDIVIDUAL

  • You may be required to provide documentation to prove you have the legal authority to exercise the rights of the individual.
  • PART 4 - SIGN OFF

  • You will be contacted within 30 days of the receipt of your request to advise of how it will be handled.
  • PART 5 - OTHER