Request to Amend Protected Health Information Form

This is a request to amend protected health information form that you can customize and share online using our form builder. This form is for covered entities that collect requests from patients to amend or correct their health information in accordance with HIPAA regulations. The template uses multiple pages, field validation, electronic signature, and specific questions that you can personalize. You can also change the design of the form on 123FormBuilder and integrate the form with your internal systems. The Enterprise subscription on 123FormBuilder grants access to our HIPAA-compliant form builder and high-level features we can tailor for you.