Compliance and Privacy Links:

Amend My Record

You have the right to request an amendment to your PHI but we may deny your request for amendment, if we determine that the PHI or record that is the subject of the request:

was not created by us, unless you provide a reasonable basis to believe that the originator of PHI is no longer available to act on the requested amendment;
is not part of your medical or billing records or other records used to make decisions about you;
is not available for inspection as set forth above; or
is accurate and complete.

In any event, any agreed upon amendment will be included as an addition to, and not a replacement of, already existing records. To request an amendment to your PHI, you must submit your request in writing to the Privacy Officer, along with a description of the reason for your request. LIBERTY will act on your request within 60 days.

To request a copy, complete the <Amend Record Form> below:

First Name

Last Name

Address (line 1)

Address (line 2)

City

State

Zip Code

Phone

Email Address

What record would you like corrected?

Provide explanation of the correction needed.

What is the date of the record that needs correction?

Please only click Submit once