You may download a copy of this form:
Request to Amend My Protected Health Information
- If you cannot download the release form, please call (410)-955-6043 or (410) 955-6044 and a copy will be faxed or sent to you.
- Complete and sign the form. Be sure to fill it out completely, including dating it. Incomplete forms may be returned to you for completion.
- If you are the healthcare agent, court appointed guardian, holder of a medical power of attorney or similar legally appointed representative, please attach proof of your authority to act on behalf of the patient.
Send the completed form DIRECTLY to the following address:
Johns Hopkins Privacy Officer 5801 Smith Avenue McAuley Hall, Suite 310 Baltimore, MD 21209 Fax: 410-735-6521
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