Request to Amend the Designated Record Set - Hill Physicians Medical Group

California Addendum

To request that Hill Physicians Medical Group amends the designated record set, please contact your provider’s office directly.

Is this request for yourself?(Required)

Yes, this request is for myself

No, this request is on behalf of someone

Hill Physicians Member First and Last Name(Required)

Prefix First Last

Individual's Health Plan Member No.(Required)

I am the authorized representative of:(Required)

I am submitting this addendum request for and on behalf of the above Hill Physicians member for the following reason(s):(Required)

I request that Hill Physicians Medical Group, Inc. (“Hill Physicians”), and any and all business associates who are currently in possession of or will be in possession of all or a portion of the Hill Physicians designated record set (DRS), amend the DRS to include the following comment(s):(Required)

Not to exceed 250 words

Date that original record was created:(Required)

Reason for addendum:(Required)

Dated(Required)

Signature(Required)

Please print your full name here

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