Requests to Amend a Medical or Dental Record 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your personal information, including your full name, date of birth, medical record number, address, preferred phone number, and email address.
3. In the 'Amendment Request' section, attach any relevant medical record documents that support your request for amendment.
4. Specify the date(s) of service and the clinician of record. Clearly describe what you believe is incorrect about the entry in question.
5. Indicate how you learned about the error by checking the appropriate box. If applicable, provide names and addresses of persons or organizations to notify if your request is granted.
6. Sign and date the form. If you are not the patient, indicate your relationship and provide proof of legal authority if necessary.

Start using our platform today to easily complete your Requests to Amend a Medical or Dental Record for free!