Request to Correct/Amend your Medical Record
Please follow the steps below to submit a request to correct or amend your medical record.
- Download and print the form:
Request for Correction/Amendment of Health Information
- Complete and sign the form
Please note that electronic signatures are not accepted.
- Submit the complete form via email, fax, or mail
Email: HIM.Data.Integrity@pvhmc.org
Fax: 909.620.0474
Mailing address:
Pomona Valley Hospital Medical Center
Attn: Health Information Management – Data Integrity
1798 N. Garey Ave, Pomona, CA 91767
