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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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