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Denial of Request for an Amendment

To: _____ Date: _____ Name of Individual

Your request to amend your Protected Health Information to Kentucky State University has been denied because (state basis for denial):

___

Date: _____

Responsible Party's Name (Print)

Title of the persons or offices responsible for receiving and processing the request

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:

___

Name of Department

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.

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:

Samantha Todd, APRN

Kentucky State University

Student Health Services

400 East Main Street

Frankfort, KY 40601

Telephone: (502) 597-6277

E-mail: Samantha.Todd@kysu.edu

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