DRAFT

Version 3/FINAL: 2/1/2013

Per 12/28/2000 Rule
SAMPLE LETTERS REGARDING AN INDIVIDUAL’S REQUEST
FOR AMENDMENT OF HEALTH INFORMATION

Disclaimer
This document is Copyright © by the HIPAA Collaborative of Wisconsin (“HIPAA COW”). It
may be freely redistributed in its entirety provided that this copyright notice is not removed. It
may not be sold for profit or used in commercial documents without the written permission of
the copyright holder. This document is provided “as is” without any express or implied
warranty. This document is for educational purposes only and does not constitute legal advice.
If you require legal advice, you should consult with an attorney.

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Version 3/FINAL: 2/1/2013
Per 12/28/2000 Rule
SAMPLE LETTER ACCEPTING INDIVIDUAL’S REQUEST FOR
AMENDMENT OF HEALTH INFORMATION

Mr. John A. Doe

123 Blank Street
Anytown, Wisconsin 12345

January 1, 2013

Record #: 123456
Filed: 00-00-00
Completed: 00-00-00

Dear Mr. Doe:

Thank you for submitting to us your “Request for Amendment/Correction of Health

Information.” Your request was forwarded to the ______________________ (designated
official) for review.

Your request has been accepted, and the appropriate amendment has been made and added to
your record. If you so indicated on your initial request, the amended information will be
forwarded to the organizations or individuals you identified. If you did not indicate that we
should forward the information, but would like us to do so, or if you would like us to forward the
information to additional organizations or individuals, please contact (contact name (or
department), address, and phone number).

[Covered entity may want to include a statement about providing verification that the
amendment is included in the electronic record or provide a paper copy.]

Thank you for providing us with this opportunity to serve you and improve the accuracy and
completeness of your health information. We look forward to continuing to serve your
healthcare needs.

Sincerely,

Jane A. Doe, Privacy Officer

Anytown Community Hospital

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Version 3/FINAL: 2/1/2013
Per 12/28/2000 Rule
SAMPLE LETTER DENYING INDIVIDUAL’S REQUEST FOR
AMENDMENT OF HEALTH INFORMATION

Mr. John A. Doe

123 Blank Street
Anytown, Wisconsin 12345

January 1, 2013

Record #: 123456
Filed: 00-00-00
Completed: 00-00-00

Dear Mr. Doe:

Thank you for submitting your “Request for Amendment/Correction of Health Information.”
Your request was forwarded to the ______________________ (designated official) for review.

Your request has been denied for the following reason(s):

 The information was not created by this
organization.
 The information is not available to you for
inspection as permitted by federal law (e.g.,
psychotherapy notes).
 The information is not part of your designated
record set.
 The information is accurate and complete.

[If Wis. Stat. 51.30 records are included in the amendment denial, the following must be stated
as required by Wis. Stat. 51.30(4)(f): Your amendment request and our denial document will
be included in your designated record set and released whenever the information at issue is
released.]

After reviewing this decision, you may:

1. Send a written appeal (hereafter referred to as a “Statement of Disagreement” or “SOD”) to

(name and address of the person/office to send it to) specifying why you disagree with this
denial. It will be forwarded, along with all documentation regarding this amendment request
to a third party within our organization (who was not involved with the initial denial
decision) for further review. The original denial will be overturned or upheld in this review.
You will be notified of the appeal decision in writing within _____ days of the receipt of
your SOD at our organization.

2. Send a written notification to (name & address of person/office to send it to) indicating that
you do not wish to take further action, and request that we include a copy of your “Request
for Amendment of Health Information” and this denial letter with any future disclosures of
the protected health information that was part of your amendment request. It will be made
part of your permanent record.

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Version 3/FINAL: 2/1/2013
Per 12/28/2000 Rule
3. Accept the denial and do nothing. If no written appeal (#1) or notification (#2) is received
within ____ days, (organization’s name) has no obligation to include any documentation
related to this request for amendment with any future disclosures of health information that
was part of your amendment request.

If you feel that you would like to file a complaint with the Secretary of the federal Department of
Health and Human Services, you can obtain information at http://www.hhs.gov/ocr/privacy/
hipaa/complaints/index.html or send a letter to [name of HHS regional office and address].

Sincerely,

Jane A. Doe, Privacy Officer

Anytown Community Hospital

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Version 3/FINAL: 2/1/2013
Per 12/28/2000 Rule

SAMPLE LETTER RESPONDING TO INDIVIDUAL’S

STATEMENT OF DISAGREEMENT FOR DENIAL OF
AMENDMENT OF HEALTH INFORMATION

Mr. John A. Doe

123 Blank Street
Anytown, Wisconsin 12345

January 1, 2013

Record #: 123456
Filed: 00-00-00
Completed: 00-00-00

Dear Mr. Doe:

We received your “Statement of Disagreement” in response to our letter notifying you that we
denied your “Request for Amendment/Correction of Health Information.” As part of the
amendment request procedure, your initial request, your statement of disagreement, and
supporting documents were forwarded for further review to a third party within our organization,
who was not involved in the original decision to deny your request.

After considering your initial request, our denial of the request, and your statement of
disagreement, along with your record, the third party determined that:

 The initial “Request for Amendment/Correction of Health Information” that you

submitted will be honored and the requested amendment will be made.

 Your request continues to be denied. Your request for amendment, our denial of the
request, your statement of disagreement, and our rebuttal statement, will be added to your
record and will be included with any future disclosures regarding that information.
(Please note that a “rebuttal statement” is not required. If our organization prepared one,
it is enclosed with this letter.)

If you feel that you would like to file a complaint with the Secretary of the federal Department of
Health and Human Services, you can obtain information at http://www.hhs.gov/ocr/privacy/
hipaa/complaints/index.html or send a letter to [name of HHS regional office and address].

Sincerely,

Jane A. Doe, Privacy Officer

Anytown Community Hospital

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Version 3/FINAL: 2/1/2013
Per 12/28/2000 Rule
SAMPLE LETTER NOTIFYING INDIVIDUAL OF NEED FOR
A 30-DAY EXTENSION IN RESPONDING TO REQUEST
FOR AMENDMENT OF HEALTH INFORMATION
**NOT PERMISSIBLE FOR WIS. STAT. 51.30 RECORDS**

Mr. John A. Doe

123 Blank Street
Anytown, Wisconsin 12345

January 1, 2013

Record #: 123456
Filed: 00-00-00
Completed: 00-00-00

Dear Mr. Doe:

Thank you for submitting to us your “Request for Amendment/Correction of Health

Information.” Your request has been forwarded to the ______________________ (designated
official) for review.

At this time, we are notifying you of the need for a 30-day extension in processing your request
for amendment. This extension is necessary for the following reason(s):

(Insert Explanation/Reason for Extension)

We will have a decision made by (enter date which must be within 90 days of the request) and
you will receive written notification of the decision.

Thank you for providing us with this opportunity to serve you and improve the accuracy and
completeness of your health information. We look forward to continuing to serve your
healthcare needs.

Sincerely,

Jane A. Doe, Privacy Officer

Anytown Community Hospital

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