Complete the Amendment to Records Request Form (1 page) to request changes to records containing their individually identifiable health information (Protected Health Information). This information includes:
- Medical Records;
- Claims, Payment and Billing Records; and
- Eligibility Determination Records.
A personal representative may also use the form to request changes to records containing protected health information, however, legal verifying and authorizing the authority of the personal representative documentation must accompany the form.
The Amendment Request Form (1 page) can be printed, completed and returned as appropriate to a DHHS District Office, New Hampshire Hospital, Glenncliff Home for the Elderly, or other DHHS location. Or, send the request to:
NH DHHS
Office of Improvement & Integrity
Privacy Officer
129 Pleasant St., Brown Building
Concord, NH 03301 |
