Request for Ambulance Transport Patient Care Report

New Carlisle Fire Dept.

Request for Patient Care Report
New Carlisle Fire Department Patient Request for Access to Protected Health Information Ambulance Transport Patient Care Report
Patient Name
Date of Request

MonthDayYear
Date
Patient Address
City
State
Zip Code
Social Security Number of Patient
Last Date of Service

MonthDayYear
Date
Patient Rights: As a patient, you have the right to access, copy, or inspect your protected health information, or PHI, in accordance with federal law. You may also have the right to request an amendment to your PHI or request that we restrict the use and disclosure of it. These rights are further described in our Notice of Privacy Practices and in other policies that you may have upon request.

To better allow us to process your request, please indicate the type of request you are making on this form: [Check all that apply.]
Access to simply review my health information.Access to obtain copies of my health information.Access to review and potentially request amendment of my health information.Access to review and potentially request an accounting of how my PHI has been used and disclosed to others.Access to review and potentially request restrictions on the use and disclosure of my health information.Other Healthcare Provider involved in the treatment of this patient.
Where should the report be sent to?
example@example.com
Patient Signature

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Request Date

MonthDayYear
Date
Signature of person requesting record (if not patient).

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Name of person requesting record (if not patient).

First NameLast Name
Affiliation of person requesting record (if not patient).
Please upload any documentation related to this patient care report request.

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New Carlisle Fire Dept.