Request to amend protected health information (PHI)

Request to amend protected health information ( PHI ) Date of request : Patient Name : Date of birth : Mailing address Telephone number :
What PHI would you like changed ? Please include treatment dates and physician names if you know them .
Why would you like this PHI changed ?
Renown Health may deny your request to amend your PHI if :
• Renown did not produce the record
• The record has been reviewed and is considered accurate and complete
• You do not have the right to access the information you want changed
• The information you want changed is not used to make decisions about your care
Signature of patient : OR Signature of Personal Representative Relationship to patient :
( If patient is not a minor child , please include a power of attorney or other documentation demonstrating signer ’ s authority to request this on the patient ’ s behalf )
Please send completed form to : Renown Health Health Information Management 1155 Mill St , MS 012 Reno NV 89502
If you do not receive an acknowledgement letter regarding this request within 7 days , please call the number below or email statuscheck @ renown . org .
Request to amend PHI
Health Information Management Release of Information 1155 Mill St ., MS 012
Reno NV 89502 Phone 775-982-2790
Fax : 775-982-3759
Document Type Bar Code
Patient Label
[ Type text ]
Form Number : 100-027 Revision Date : 5 / 2023