Identity Theft Resource Center Letter Form 130A Request to Receive and Correct Medica... Page 1 of 2
From Identity Theft Resource Center
Letter Form 130A Request to Receive and Correct Medical Records Posted in: Letter Templates By Jun 1, 2007 - 2:05:13 PM
Letter Form 130A Request to Recieve and Correct Medical Records For medical identity theft victims, here is some language that may be useful in making a case for removing incorrect information from a health provider’s record: Your name, address, city, state, zip, phone number, email address, health insurance number (to assist in finding your file) This is being sent via certified mail: #_______________________ on (date) :__/__/__ Agency Name,
Date:__/__/__
Address I may be a victim of medical identity theft because _________. (Examples: I received a bill from you or a notice that someone attempted to obtain prescriptions, health insurance benefits or medical services in my name). The medical records your agency maintains about me may include information about someone else. This information, if not corrected, may adversely affect my personal health care and/or deny me insurance benefits. I am requesting the following: *To receive a copy of my medical records so that I can review them for information that may not pertain to me. z z
z z
In the event that you cannot send the records to me, I would like to set a date to come in and review the records in your local office. Once I review the records, to have a “statement of disagreement� placed in a conspicuous location on my medical records. It will serve as an alert for other health providers of the medical identity theft issue and to verify my medical information prior to making a diagnosis or prescribing medication. To request that you notify any other entity that you have shared my records with of the corrections. A letter from your agency that the corrections have been made.
Your agency may have received fraudulent information from an identity thief. It is apparent that we both have a vested interest in identifying misinformation and resolving this situation. Should you have any questions regarding my request, please contact me at: _____________________________________________ Sincerely, (your name)
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Identity Theft Resource Center Letter Form 130A Request to Receive and Correct Medica... Page 2 of 2
Sample “Statement of Disagreement” - your list might be considerably longer Name, address, phone, email, patient record number, date
I have become aware of misinformation on my medical records in your possession. The affected dates seem to occur between April 2006 and June 2006. The following information needs to be removed or amended: z z z z z z
Blood type – I am type A+ positive and not O- negative Physical description – I am not 5’3” tall white male. I am 6’ tall Hispanic male I have never had my appendix removed I am NOT allergic to penicillin. I am allergic to the following items: (list) I have never lived at ________ I do not have, nor have I ever had treatment for, a sexually transmitted disease
Fact Sheet 130A Correcting Misinformation on Medical Records
Copyright March 2007, Identity Theft Resource Center®, all rights reserved. Created by the ITRC This fact sheet should not be used in lieu of legal advice. Any requests to reproduce this material, other than by individual victims for their own use, should be directed to ITRC. © Copyright 2008 by Identity Theft Resource Center
http://www.idtheftcenter.org/artman2/publish/v_templates/Letter_Form_130A_Request_to_... 12/30/08