REQUEST TO AMEND PROTECTED HEALTH INFORMATION BY PARENT, GUARDIAN OR LEGAL REPRESENTATIVE DHCS 6239a: Fill out & sign online

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Click ‘Get Form’ to open it in the editor.
Begin by filling in the 'File Number' at the top of the form. This number is essential for tracking your request.
In the 'CLIENT WHOSE INFORMATION YOU ARE AMENDING' section, provide the client's last name, first name, address, city/state, client index number (CIN), date of birth, and if applicable, date of death.
Next, complete the 'PARENT, GUARDIAN, OR LEGAL REPRESENTATIVE INFORMATION' section with your details including last name, first name, address, and contact numbers.
Indicate your legal authority to amend the health information by selecting one of the options provided and attach any necessary legal documentation.
Identify the protected health information you wish to amend and specify what you want it to state now. Provide a reason for this amendment.
List any individuals who should receive copies of the amended information along with their addresses.
Attach a copy of your identification and any required address verification documents before signing and dating the form.

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What is a request to amend?

Prepare and send a written response to the patient within 60 days of receipt of the original request. Sign and date the response. Indicate on the patients record that per the patients request, the record is amended as follows, and make any appropriate changes.

What is amend protected health information?

An individual has the right to have a covered entity amend protected health information or a record about the individual in a designated record set for as long as the protected health information is maintained in the designated record set.