Address: - uclahealth 2026

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The document is a request form for patients to amend their protected health information (PHI) at UCLA Health. It requires the patient's details, the specific information they wish to change, reasons for the request, and instructions on where to send the amended information. The form also outlines conditions under which UCLA Health cannot amend PHI.

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Click ‘Get Form’ to open it in the editor.
Begin by entering your name in the designated field. Ensure that it matches your official documents for accuracy.
Fill in your address in the provided section. This is crucial for any correspondence regarding your request.
Enter your date of birth and phone number accurately to help verify your identity.
In the section asking for the protected health information you wish to amend, clearly state what needs changing and provide reasons for this request.
If applicable, list any individuals who should receive the updated information. If no one should be notified, select that option.
Finally, sign and date the form at the bottom. If someone else is signing on your behalf, specify their relationship to you.

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