Patient Amendment Notice of Denial Letter Form

Sep 15, 2026

Uploaded by Maeve

Template letter for denying a patient’s request to amend health information. The letter states the date and patient identifiers, explains the specific denial reasons (such as an unwritten request, insufficient explanation, unavailable or non-eligible information, lack of entitlement to inspect, or belief the data is accurate and complete), and informs the patient of rights. It describes the option to submit a written disagreement statement limited to two pages and outlines where to send it, plus complaint filing options without retaliation.

LanguageEnglish

CategoryLetters

FormatPDF

Pages2

Reading Time1 min

AccessFree to download

Denial Notice of Request To Amend Health Information

Reasons for Denial

Right to Submit a Statement of Disagreement

Filing a Complaint

REQUEST FOR AMENDMENT-NOTICE OF DENIAL LETTER [Date] [Patient Name][Street Address 1] [Street Address 2] [City, State Zip Code] Re: Denial of Request To Amend Health Information Dear [Patient Name]: This letter responds to your request that we amend your health information, which we received from you on . For the reasons stated below, we are denying your request: 􀀁 The request was not in writing. 􀀁 The request did not explain why you believe we should make the amendment. 􀀁 The information you would like to have amended is not available in records that we use to make decisions about you or your treatment. 􀀁 The information you would like to have amended was not created by SUNY Downstate. You may wish to ask the person or organization that created the information for an amendment. 􀀁 The information you requested cannot be amended because you are not entitled to inspect this information. The reason you are not entitled to inspect the information is 􀀁 We believe that the information is not inaccurate and incomplete without the amendment you requested. You have the right to submit a statement explaining your disagreement with our decision to deny the amendment you requested. This statement must be in writing and should be no longer than two (2) pages. We will include your statement, or an accurate summary of it, any time we disclose to others the protected health information that you think should have been amended. However, we reserve the right to prepare a response to your statement of disagreement, called a rebuttal statement, which we may also include when we make future disclosures of the information that you think should have been amended. If you wish to exercise this right, please send your statement of disagreement to: SUNY Downstate Medical Center University Hospital of Brooklyn Department of -Box \# Correspondence Unit 450 Clarkson Ave. Brooklyn, NY 11203 If you do not submit a statement of disagreement, we will include only your amendment request and this denial notice in any future disclosures of the information which you think should have been amended. We hope that you will understand the reason that we have denied the amendment you requested. However, if you believe that we have improperly handled your request, you may file a complaint with us or with the Secretary of the United States Department of Health and Human Services. To file a complaint with us, please contact the Department of Patient Relations at (718) 270-1111. No one will retaliate or take action against you for filing a complaint. Sincerely, Department

FAQs

What must the patient include in the denial notice letter?

The letter includes the date, patient name and address, and a reference line stating denial of the request to amend health information. It also lists the applicable reasons for denial and provides next-step instructions.

What reasons are commonly given for denying an amendment request?

Reasons include the request not being in writing, not explaining why an amendment should be made, the information not being available in the records used to make decisions, the information not being created by SUNY Downstate, and situations where the patient is not entitled to inspect the information or where the information is believed to be accurate and complete.

How can the patient respond or file a complaint after denial?

The patient may submit a written statement of disagreement, limited to two pages, and send it to the specified SUNY Downstate Department address. If the request was mishandled, the patient may file a complaint with the Department of Patient Relations or the U.S. Department of Health and Human Services Secretary, and the letter states there will be no retaliation.

Sep 15, 2026

Uploaded by Maeve