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            {
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                "text": "Request for Amendment to\nProtected Health Information",
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                "level": 1
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                "text": "Name: ___ Date: ___",
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                "text": "I hereby request that Kentucky State University, Betty White Student Health Services, amend:",
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            {
                "page": 1,
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                "text": "Please identify the relevant persons or entities who need to be informed about the amendment:",
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            {
                "page": 1,
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                "text": "Please state the reason(s) supporting the requested amendment:",
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                "text": "Signature of Individual (or Legal Representative) Date",
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            {
                "page": 1,
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                "text": "Individual's Name (Print)",
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                "text": "Name of Legal Representative, if applicable (Print) Relationship to Individual",
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                "text": "Responsible Party's Name (Print)",
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                "text": "Date",
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