Follow the steps to accurately complete your form.

1. Select the ‘Get Form’ button to access the correction request form and open it in the editing interface.
2. Fill in the patient information section with the following details: patient name, date of birth in MM/DD/YYYY format, gender, race, ethnicity, street address, city, state, ZIP code, primary care office, and insurance provider.
3. Provide your contact information, including your cell phone number, home phone number, primary email address, and alternate email address. If applicable, include your prior street address, city, state, and ZIP code.
4. Attach a copy of your COVID-19 vaccination record and any other necessary documentation required for your request.
5. Indicate the corrections or actions required by checking the appropriate boxes. If you are requesting an addition or correction to your COVID-19 vaccination record, attach the relevant vaccination documentation.
6. To correct personal information (name, address, email, phone number, date of birth), ensure to attach proof of identity in accordance with the guidelines provided. This can include a government-issued ID or two documents that verify your name and current address.
7. Carefully read the authorization statement, then sign and date the form to certify that you have the legal right to request the changes and that all information provided is accurate.
8. After completing the form, save any changes you have made. You can then download, print, or share the form as needed.

Take the next step towards updating your records by completing your form online today.