Medical Record Amendment Request Form

You have the right to request to amend health information we maintain about you or your child if you believe the health information is inaccurate or incomplete. Please note, this does not include routine changes such as change of address or phone number.

All of the following form fields below must be completed. If left blank, this could lead to delay in the processing of your request. If the patient is a minor, the legally authorized representative must complete this form. If the patient is an adult, they must complete the form themselves.

No later than 60 days after you submit this completed form, you will receive a written response to your request via mail from Nationwide Children’s Hospital.

Please specify 1 of the 2 fields so we can properly verify your identity:

Please tell us what health information you would like us to amend. Be as specific as possible regarding the record type, where the record was generated, and the date. (For example, “I would like to amend my child’s ABC Laboratory test results dated December 5, 2010” or “all records reflecting my child’s blood type as O positive”)

Please tell us why you want the health information amended. Be as specific as possible about the reason. (For example, “My child never received a blood test from ABC Laboratory” or “my child’s blood type is O negative”)

If the amendment is accepted, you may request that we notify others that you believe received the information in the past. By providing names below, you authorize Nationwide Children’s Hospital to notify them of the amendment.

If you have any questions or need additional support with your request, please contact the HIM department by phone at 614-355-0852, or by email at