Alden, NY · Erie County
Request for an Amendment of Health Information
This three-page form lets patients and authorized representatives ask Erie County to correct or complete health information maintained in a designated record set.
- licensed online notary
- ~15 min average
- Notarized PDF emailed
What you’ll need
- Government-issued photo ID
- Webcam-enabled device (laptop or phone)
- This form, ready to upload as a PDF
What this form is
Use this form to identify the health information you believe is incorrect or incomplete, explain the requested correction, and provide patient or representative details. Erie County requires notarization when the request is submitted by mail; in-person requests have separate identification and verification requirements. An authorized representative submitting a request must also provide a copy of the document showing their authority. Return the completed form to the Erie County Chief Privacy Officer at the address or email listed on it.
Who needs it
Patients or authorized representatives seeking to amend health information maintained by Erie County in a designated record set should complete this form.
Why it needs a notary
The form carries an acknowledgment block, which the patient or authorized representative signing a mailed request must complete before a notary.
How to get this notarized
- 1
Download The Form
Get the Request for an Amendment of Health Information form from Erie County.
- 2
Complete The Request
Enter patient or representative details, identify the information to amend, explain the requested correction, and attach any required representative-authority document.
- 3
Book An Online Notary
Arrange a video appointment with a commissioned online notary for the acknowledgment on a mailed request.
- 4
Sign On Video
Follow the notary's instructions and sign the form during the online notarization session.
- 5
Submit To Erie County
Send the completed request to the Erie County Chief Privacy Officer using the address or email shown on the form.
Preview the form
The blank PDF straight from Alden. Look it over, then upload your filled copy to start the notary session.
You’ll need ID and a webcam.
A licensed online notary will join you on video, verify your government-issued ID, witness your signature, and apply their seal. You’ll receive the notarized PDF by email when the session ends.
Frequently asked questions
- How do I submit a request to amend Erie County health information?
- Complete the form with the information you want amended and why it should change. Send it to the Erie County Chief Privacy Officer using the address or email on the form; mailed requests require notarization.
- Do I need notarization for this amendment request?
- Yes, if you submit the request by mail. The form says in-person requests can meet verification requirements with government-issued photo identification, and representatives must provide supporting authority documents.
- Can I sign this form with a commissioned online notary?
- New York authorizes remote online notarization for its own notaries under Executive Law §135-c, in effect since 2023. Ask the Erie County Chief Privacy Officer whether an online-notarized mailed request meets its submission requirements.
- What should I do if I am unsure about the submission requirements?
- Contact the Erie County Chief Privacy Officer using the contact details on the form. For local filing questions, confirm with the city, town or village if unsure.