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                    "text": "Responsible Party's Name (Print)",
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                    "text": "You may have the right to submit a written statement of disagreement. If you have the right to submit a written statement of disagreement, submit it to:",
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                    "text": "If you do not submit a written statement disagreeing with the denial, you may request, in writing, that we provide your request for amendment and our denial with any future disclosures of the Protected Health Information that is the subject of your request.",
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                    "text": "You may make a complaint to the University’s Privacy Official regarding the denial of your amendment. The contact information for the Privacy Official is:",
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                    "text": "Samantha Todd, APRN",
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                    "text": "Student Health Services",
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                    "text": "400 East Main Street",
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                    "text": "Frankfort, KY 40601",
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                    "text": "Telephone: (502) 597-6277",
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                    "text": "Continued to next page",
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