Get Phi Amendment Request - Intermountain Healthcare

Completing the PHI Amendment Request is essential for addressing any inaccuracies in your personal health information. This guide provides clear, step-by-step instructions to navigate the amendment process effectively and ensure that your concerns are properly addressed.

Follow the steps to complete the PHI Amendment Request online.

1. Press the ‘Get Form’ button to obtain the PHI Amendment Request form and open it in the online editor.
2. Fill in your personal information. Include your full name, date of birth (DOB), current address, medical record number (MRN), and any other relevant information.
3. If applicable, provide the name of your personal representative who is requesting the amendment on your behalf. Fill in their contact details as well.
4. Clearly describe the information in your health records that you believe is inaccurate. Use the space provided to detail the inaccuracies with as much specificity as possible.
5. Explain why you believe the information is not accurate. This is a crucial component of your request, so be thorough in your reasoning.
6. List any documents that contain the information you are referencing, as well as the specific treatment dates related to these records.
7. Sign and date the request. If someone other than yourself is submitting the request, include their relationship to you.
8. After completing the form, review all entries for accuracy, save your changes, and then download, print, or share the form as needed.

Start completing your PHI Amendment Request online to ensure your health information is accurate.