Request for Amendment & Restriction
Request for Restriction of Protected Health Information
The HIPAA Privacy Regulations provides an individual the right to request restrictions on the uses or disclosures of their protected health information when the uses and disclosures are for treatment, payment, health care operations, and certain uses and disclosures to persons involved in the individual’s care or for notification purposes. (45 CFR 164.522) The HIPAA Privacy Regulations do not require that a request for restriction be approved unless the request is to restrict disclosures to a health plan and the following applies: • the disclosure is to carry out payment or health care operations; • the disclosure is not required by law; and • the protected health information pertains solely to a health care item or service for which Infirmary Health has received payment in full from the individual prior to the service being provided. (HITECH Act Section 13405(a) & 45 CFR164.522(a)(vi).
If you have any questions, please contact Infirmary Health Privacy Officer at 251-435-5743.
Please email the completed form to
ROI@infirmaryhealth.org or mail to:
Infirmary Health
Attn: Health Information Management
5. Mobile Infirmary Circle
Mobile, AL 36607
Requests will be reviewed by the Infirmary Health HIPAA Committee within 60 days of the request.
Request for Amendment of Protected Health Information
Infirmary Health System (IHS) and/or the health care provider that documented the information being requested for amendment may deny your request if:
- The information was not created by IHS;
- It is not part of a IHS designated record set, such as the medical record;
- It is not part of the information which you would be permitted to inspect and copy/ or;
- IHS and/or the health care provider determine the information is accurate and complete.
IHS will respond to your response within 60 days of receiving the request. If IHS is unable to act on the request for amendment within 60 days, the organization with notify you in writing prior to the end of the 60 day deadline extending the process for another 30 days. For more information on the Amendment Request process, you can contact the Corporate Compliance Office at 251-435-5823.
Please email the completed form to
ROI@infirmaryhealth.org or mail to:
Infirmary Health
Attn: Health Information Management
5. Mobile Infirmary Circle
Mobile, AL 36607
