Denial Letter Template | for Protected Health Information (PHI) Amendment Requests
_____________________Organization Logo Here________________________
Date: ____/ _____ / ______
_________Address Here_________
________Recipient Name Here_________
____Organization Name Here___ is unable to ________Denial Reason Here_______.
You, or your legal representative has the right to submit a written statement disagreeing with the reason provided, to:
Privacy Officer
_____Organization Name Here_____
_____Address Here_________
You or your legal representative may complete and submit an “Authorization for Release of Health Information” form requesting that _____Organization Name Here_____ provide your completed amendment request form and this denial letter with any future disclosures of your or the patient’s health information that relates to the records’ amendment request that you submitted: That is only if you or your legal representative does not submit a written statement of disagreement.
You or your legal representative may complain or continue to complain in writing to ____Organization Name Here_______:
Privacy Officer | __________Organization Name Here________
______________________Address Here________________
________Privacy line Number Here_______
Or to the Secretary of the Department of Health and Human Services.
Enclosed: “Your completed amendment request form” / “Authorization or Request for Release of Health Information form”
The Privacy Office | _______Organization Name Here_________
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