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INDIAN RIVER COUNTY <br /> INDIVIDUAL RIGHTS FORMS <br /> INDIVIDUAL REQUEST TO CORRECT OR AMEND A RECORD <br /> I request the group health plan to amend the protected health information in its designated record <br /> set. <br /> Specific Statement of Amendment Request <br /> Specific Reason for Amendment Request <br /> I understand that if the protected health information was not created by the group health plan, the <br /> group health plan is not required to honor my request. For example, if the information I wish to <br /> amend is in a medical report created by my physician, I must ask the physician — not the plan — <br /> to amend the report. I also understand that if the information is not available for my inspection, <br /> is not part of the plan' s designated record set or is already accurate and complete, I cannot amend <br /> the information. <br /> I understand that the group health plan will respond to my, request within 60 days . <br /> Signature : Date. <br /> • <br />