Request to amend medical records
Instructions to follow when requesting a change or correction to an existing record.
To amend or correct your or your family members medical records, we ask that you complete the following steps:
1. Print the PATIENT REQUEST FOR AMENDMENT/CORRECTION OF PROTECTED HEALTH INFORMATION form.
2. Complete the form, providing the date(s) of service, the information you are requesting to amend or correct, and the reason for making the request.
3. Your signature must appear on the form to be considered valid. Electronic signatures or Adobe-generated signatures are not accepted.
4. Once the form has been completed and signed, you may either email the form to firstname.lastname@example.org or you may mail it to CityMD, ATTN: Privacy Officer, 1345 Avenue of the Americas, 8th Floor, New York, New York 10105.
Please note that CityMD may take up to 60 days from the date the request is received to provide you with a response. In the event CityMD is unable to provide you with a response within 60 days of the receipt of your request, CityMD will send you with a written notification explaining the reasons for the delay and providing the date by which you will receive a response to your request.