Skip Navigation
Forms On Library (3)
  • Form

Sample HIPAA Policy Template: Patient Requests to Amend Medical Records

Our sample template to create a policy for patient requests to amend medical records can be downloaded and customized for use at your medical practice.

The purpose of this sample policy template is to establish procedures in accordance with the requirements of 45 CFR 164.526 for receiving, processing, and timely responding to patients’ requests to amend protected health information in their designated record set. HIPAA defines the “designated record set” to include medical records, billing and payment records, health insurance information, clinical laboratory results, medical images such as x-rays, wellness and disease management program files, clinical case notes, and other information used to make decisions about patients.

This sample template is for general informational purposes to help you create a customized policy and procedure that fits your practice. This sample should not be considered as legal advice. Please consult with an attorney to ensure compliance with state laws, rules, and regulations surrounding amending medical records. You can download and customize this template. Be sure to complete the blank fields with your practice-specific information.

  1. Download Form