Other Requests Related to Your Health Records

Other Requests Related to Your Health Records

To request an amendment or restriction of your health information, or to obtain an accounting of disclosures:

Download and complete all fields on the appropriate form

Submit the form by:

  • Fax: 312.926.7686
  • Email: himmedrc@nm.org
  • Mail: ATTN: Data Integrity Patient Privacy 676 N St Clair Street Suite 1840 Chicago, IL 60611

Amendment Request: Ask us to correct or amend your medical record (+ sign with details)

  • You can ask us to correct health information about you that you think is incorrect or incomplete.
  • We may say “no” to your request, but we will tell you why in writing, usually within 60 days of your request.

Patient Request for Amendment of Protected Health Information Form
Process Overview: Patient Request for Amendment

Restriction Request: Ask us to limit what we use or share (+ sign with details)

  • You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to these requests. For example, we may say “no” if it would affect your care.
  • If you pay for a service or healthcare item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.

Patient Request for Restriction of Protected Health Information Form

Accounting of Disclosure: Obtain a list of those with whom we’ve shared your information (+ sign with details)

  • You can ask us for a list (accounting) of the instances we have shared your health information for six years prior to the date you ask, with whom we shared it, and why.
  • We will include all the disclosures except for those about treatment, payment or healthcare operations, and certain other disclosures (such as any you asked us to make). We will provide one accounting per year for free but may charge a reasonable, cost-based fee if you ask for another one within 12 months.

Patient Request for Accounting of Disclosures Form

Contact Us

If you have questions about a request for amendment, restriction, or accounting of disclosures, contact Health Information Management at 312.472.6550.