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)

Consent(Required)

I understand that Hill Physicians may deny my request for any of the following reasons within 30 days of receipt of this request:

1. Hill Physicians did not create the PHI or record.

2. The PHI or record is not part of Hill Physicians’ Designated Record Set.

3. The PHI is not available for access pursuant to the requirements of HIPAA.

4. The PHI or record is accurate and complete.

Consent(Required)

I understand that Hill Physicians will provide notice of its denial, if any, and a detailed explanation of the basis for the denial of my Request to Amend the Designated Records Set.

Dated(Required)

Signature(Required)

Please print your full name here

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