Request for Amendment of Protected Health Information— Health Plan
NOTICE TO MEMBER: Your request for an amendment to your protected health information maintained in the designated record set
is applicable only to the information maintained by the Cameron University Health Plan. If you would like to request amendments to
your protected health information maintained by any other University entity, a separate request must be submitted to that
Address where you want the response to this request sent:
Street City State Zip
Date of the record or information you would like amended:
Describe the information you would
State the specific reason for requested amendment:
I request the amendment described above be made to the protected health information in my designated record set maintained or
ed by the Cameron University Health Plan.
Signature Title, if legal representative
May be requested to submit evidence of representative status.
Your request for amendment is approved. Please complete the attached form, Protected Health Information Amendment -
Notification Form, to identify any persons or entities that need to be notified of the amendment to your protected health
information and return the form to us.
File in Member Chart HIPAA Document
Revised 1/2015 © 2015 Retain for minimum of 6 years