Williamsport Volunteer Ambulance Service
Patient Request for Amendment of Protected Health
Information
(Please
print out, fill out all spaces below, and mail to the address at the bottom)
Patient Name:
_______________________________________________________
Address: _______________________________________________________
City: _________________ State:_____ Zip Code:_______
Information to Amend: Please
circle the field that represents the type of information you would like to
amend.
Name Billing Address
Mailing Address Current Medical
Condition
Past Medical History Current Medications
Allergies Marital
Status
Surrogate
Decision Maker Organ Donor
Other:
Please describe
__________________________________________
Please specifically describe what information you wanted
amended. Please ONLY list the new information. Attach a separate sheet if
necessary.
WVAS, in its capacity as a health
care provider, is entitled to perform and bill for services based on all
protected health information in its current form or upon which it has already
relied until such time as the amended information becomes effective. WVAS
Ambulance is not required to accept your request for amendment and will notify
you in writing as to the decision on your request. Your signature below
indicates that you have agreed to accept these terms as they have been listed
and to provide payment, if required, to WVAS based on existing protected
information until such time that the amendments you have made are effective.
Patient Signature: _______________________ Date: _________