===== PAGE 1 =====
<div style="text-align: center;"><img src="imgs/img_in_image_box_299_449_691_722.jpg" alt="Image" width="15%" /></div>


# Request for Amendment to Protected Health Information

Name: ___ Date: ___

Telephone Number: ___

I hereby request that Kentucky State University, Betty White Student Health Services, amend:

Please identify the relevant persons or entities who need to be informed about the amendment:

Please state the reason(s) supporting the requested amendment:

Signature of Individual (or Legal Representative) Date

Individual's Name (Print)

Name of Legal Representative, if applicable (Print) Relationship to Individual

Responsible Party's Name (Print)

Date