Amendment Request

Amendment Request

Use this to form to change or amend a medical record.
This form can be used to a change or request an ammendment to your medical record.
- Legal Name and/or Gender Marker changes.
- If you believe there is an error in your medical record.
Please allow 30 days for processing. Name and gender changes may require additional follow-up to ensure that all names and markers on file with insurance, Ryan White, pharmacy, immunization databases, and 3rd party labs are updated correctly.

Documentation for Legal Name and/or Gender Marker changes:
1. Updated Photo ID
2. Updated Insurance Card
Please note that in order to get your healthcare services covered by your health insurance plan, we are required to submit insurance claims with the name and gender marker on file with your health insurance plan. Conincidently, names and gender markers on file with your health insurance are reflected in many areas of your health record, including your Patient Portal/Healow.

We recognize that in some cases, this may not align with your identity and we are actively working with our EHR vendor to adopt more inclusive and progessive technologies.
Chosen Name
Current Legal Name*

First NameLast Name
Former Legal Name

First NameLast Name
Date of Birth*

MonthDayYear
Please describe in detail the amendment you are requesting:*
Please upload any supporting documentation.

Optional
Cancelof
Take Photo of your supporting documentation.
Are you submitting this on your own behalf?*

YesNo
Who is submitting this amendment request?*

First NameLast Name
Submitter's Signature*

Clear
Date*

MonthDayYear
Date
Please verify that you are human*
Should be Empty: