Form Hch 1352 is a Form for Requesting Taxpayer Identification Number (TIN) Verification from the Internal Revenue Service (IRS). The form is used to request an IRS letter confirming that a particular taxpayer identification number (TIN) is valid. The form can be used to confirm a TIN for any purpose, including income tax filing, employment tax reporting, and other compliance purposes. Any individual or business who needs to verify a taxpayer identification number (TIN) should use Form Hch 1352. This form can be used by individuals, businesses, state and local governments, and other organizations. The verification letter provided by the IRS will confirm that the TIN is valid for the purpose requested. Form Hch 1352 must be signed by the person requesting the verification letter, or by an authorized representative of the organization. Requests can also be made online using the IRS secure website at www.irs.gov/Businesses/Small-Businesses-&-Self-Employed/Employer_ID_Number_(EIN)_Ver
| Question | Answer |
|---|---|
| Form Name | Form Hch 1352 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | hch1352 john dempsey hospital request for amendment of health information form |
University of Connecticut
Health Center
(PATIENT IDENTIFICATION)
REQUEST FOR AMENDMENT OF HEALTH INFORMATION
Patient Name: ______________________________________________________________________
Patient Address: ____________________________________________________________________
Date of Birth: _____/____/___________ Medical Record Number _____________________________
Date of Service to be amended: ______/____/___________
Date of entry to be amended: ______/____/___________ Time of entry _____:_____
am ;
pm
Type of entry to be amended: ________________________________________________________
After review of my record, I do not feel the original documentation made by _____________________
(enter name of health care provider) accurately reflects facts about my condition, diagnosis or treatment and should be corrected or clarified in the form of an addendum to my record. I understand the physician may or may not agree with my request, and under no circumstances, will alter the original documentation in the record. However, this request for an addendum will be made part of my permanent record. It will be disclosed as part of the record in response to any authorized releases of my medical information. I request the following amendment be made to my record (please explain how the entry is incorrect and indicate what the entry should say to be more accurate): If additional space is needed, please attach to this form.
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Signature of Patient (or legal representative [proof required] ) |
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PROVIDING THE AMENDMENT TO ANYONE OUTSIDE OF UCHC
Would you like this amendment to be sent to anyone we may have disclosed this information to in the past? If so, please specify the name and the address of the organization or individual.
Name of individual/organization: ___________________________________________________________________
Address: __________________________________________________________________________________________
Name of individual/organization: ___________________________________________________________________
Address: __________________________________________________________________________________________
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Signature of Patient (or legal representative [proof required] ) |
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Original – Medical Record |
Yellow – Patient |
*HCH1352* |
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University of Connecticut
Health Center
(PATIENT IDENTIFICATION)
REQUEST FOR AMENDMENT OF HEALTH INFORMATION
HEALTH CARE PRACTITIONER RESPONSE (FOR UCHC USE ONLY)
APPROVAL
In response to your request, the amendment will be added to your record.
Amendment Dictation ID #: _________________________
DENIAL
Your request for amendment has been denied for the following reason(s):
Personal health information was not created by this organization
Personal health information is not part of the patient’s designated record set
Personal health information is not for inspection as required by law (e.g., psychotherapy notes) Personal health information is accurate and complete as it stands
Other _________________________________________________________________
Though your request has been denied, the request will be included as part of your medical record.
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Signature of Health Information Management Designee |
Date |
Time |
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YOUR RIGHTS AFTER DENIAL OF AMENDMENT
If your request for amendment was denied for any reason stated above on this form, UCHC is required to inform you of your right to file a disagreement or complaint with this decision.
How to File a Disagreement:
Your statement of disagreement to our denial must be made in writing to the Health Information Department. UCHC may, upon receipt of your disagreement, write a rebuttal statement. Your statement and any UCHC rebuttal statement will be kept on file with your record and will be included in any future disclosures of this information. If you do not submit a disagreement statement, you may ask UCHC to provide a copy of your request for amendment and our denial of that request with any future disclosures of this information that UCHC makes.
You have the right to complain about the process used to handle your request:
With UCHC:
Privacy Officer
University of Connecticut Health Center
Farmington, CT 06030 Mail Code: 5329
Phone:
With the Department of Health & Human Services:
Regional Manager, Office for Civil Rights DHHS Government Center
J.F.Kennedy Federal Building – Room 1875 Boston, Massachusetts 02203
Voice Phone: (800)
FAX:
Your complaint must be in writing, filed within one hundred eighty (180) days of when you knew or should have known of the denial, and state that you are complaining against UCHC.
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