Health Information Management
Southern California Permanente Medical Group SCALPatientAmendments@kp.org
Kaiser Foundation Hospitals
REQUEST TO ADDEND OR AMEND MEDICAL RECORD
Addendum Requests: California law gives patients the right to have an addendum of up to 250 words to be
included in the relevant part of their medical record. Providers cannot deny this type of request.
Amendment Requests: Federal law gives patients the right to ask their provider to amend their designated
record set, which may include striking out information, deleting information, or appending information. The
provider may deny a request to amend a patient’s medical record.
Patients must indicate whether they want to have an addendum added to their record, or are requesting that
their record be amended, or both.
For addendum requests, complete the attached form, and submit it with an addendum of 250 words or less to
the address above, and it will be added to relevant part of the record.
For amendment requests, complete the attached form and submit it to
SCALPatientAmendmen[email protected]
• Kaiser Permanente will respond to amendment requests in writing within 60 days. If additional time is
needed to respond, notice will be given prior to the end of the 60-day period.
• We reserve the right to accept, or deny the request based on the discoveries made during the review
process, as allowed under law.
• If Kaiser Permanente denies an amendment request in whole or in part, o A written denial will be
provided that clearly outlines the reason for the denial. o Patients may provide a written Statement of
Disagreement to be included in the record.
o Kaiser Permanente must receive a Statement of Disagreement within 30 days of notice that the
amendment request has been denied.
o It must be clearly stated in writing if the Statement of Disagreement is to be included in future
disclosures we make of that part of the record.
o We may include a summary instead of the Statement of Disagreement. Please limit the
Statement of Disagreement to 250 words for each item that is believed to be incorrect or
incomplete
o The provider may prepare a written rebuttal to the Statement of Disagreement, and a copy will
be provided.
o If a Statement of Disagreement is not submitted, a request can be made that we include the
amendment request, and the denial along with all future disclosures of the medical record that is
the subject of the amendment request.
KPSC Addendum or Amendment Request 5.23.2023
Health Information Management
Southern California Permanente Medical Group SCALPatientAmendme[email protected]
Kaiser Foundation Hospitals
REQUEST TO ADDEND OR AMEND MEDICAL RECORD
Complete this form and submit it to the address shown above.
Please check the appropriate box below to indicate if this is a request to addend or amend the medical record.
Both boxes may be checked.
__ Add an addendum to the relevant part of the medical record __
Request to amend the relevant part of the medical record.
Name of Patient
Medical Record Number
Date of Birth
Address
City
State
Patient Representative*
Relationship to Patient
Email
Signature
*If you are a personal representative of the patient, please provide documentation of your authority. Please
specify which record(s) you are requesting be amended, and the reason for your request.
Date of Visit
Location of Visit
Reason(s) for Amendment Request
Have you provided copies of these records to any person or organization other than Kaiser Permanente? If
yes, and you want the accepted amendment sent to them, please list them here:
Name
Address
City, State, Zip Code
Please may attach you addendum or amendment request, or enter it below (250 words or less).
KPSC Addendum or Amendment Request 5.23.2023