Document Release Form

Who Is Requesting Information?*

Record requests for individual patients or their personal representative only (Generally, a personal representative is a person with authority under State law to make health care decisions for the individual).

Date of Service*

Date

Patient Name*

First NameLast Name

Patient Date of Birth*

Date

Pick Up Location of Patient

Contact email for attorney or paralegal to receive invoice and records via encrypted email

example@example.com

For records to be used in civil, criminal or administrative action proceedings. Request must be on attorney’s letterhead

Signed HIPAA release form must be signed and attached.

Please email our Privacy Officer if you have any further questions.

JMiller@SouthBridgeEMS.com

Phone Number*

Address*

Street Address

CityState

Zip Code

Email

example@example.com

Right to Request Access to Your PHI and Our Duties:

You (or your authorized representative) have the right to inspect or obtain a copy of your protected health information (“PHI”) that we maintain in a designated record set. If we maintain your PHI in electronic format, then you also have a right to obtain a copy of that information electronically. In addition, you may request that we transmit a copy of your PHI directly to another person and we will honor that request when required by law to do so. Requests to transmit PHI to another party must be in writing, signed by you (or your representative), and clearly identify the designated person to whom the PHI should be sent, and where the PHI should be sent.

Generally, we will provide you (or your authorized representative) access to your PHI within thirty (30) days of your request. We may verify the identity of any person who requests access to PHI, as well as the authority of the person to have access to the PHI by asking the requestor to provide the patient’s social security number, date of birth, legal authority to act on behalf of the patient (such as a power of attorney) or other information necessary to verify that the requestor has the right to access PHI. In limited circumstances, we may deny you access to your PHI, and you may appeal certain types of denials. We may also charge you a reasonable cost-based fee for providing you access to your PHI, subject to the limits of applicable state law.

Request for Access to PHI

Below, please describe the PHI that you are requesting access to with as much specificity as possible. Specify dates of service and other details that will allow SouthBridge EMS to accurately and completely fulfill your request.

Specify How You Would Like us to Provide Access:

Please check all that apply and fill out the requested information, where indicated.

I would like to inspect a copy of my PHI at SouthBridge EMS business office. SouthBridge EMS will arrange a convenient time and place for you to inspect a copy of your PHI during normal business hours.

Mail... Please send a copy of my PHI to the address indicated below:

Email Please email a copy of my PHI to the following email address indicated below:

Address for paper copy of PHI if requesting information by mail to the following:

Name

Address

CityState

Zip Code

Email address for PHI if requesting information by email

example@example.com

SouthBridge EMS uses encrypted email to protect your PHI. You will be required to follow a link to log in and create a free account in order to download your PHI.

While unencrypted email is a permissible method of PHI delivery, this method is unsecured. SouthBridge EMS cannot be held liable or assume responsibility for any PHI that is compromised as a result of transmitting your personal data by this method.

Signature of Requestor*

Clear

Typed name of signator*

Personal Representative Information (if signer is different from patient):

First NameLast Name

Relationship to Patient:

(parent, legal guardian, etc)

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Patient Authorization to Use and Disclose Protected Health Information

Right to Request Access to Your PHI and Our Duties:

Request for Access to PHI

Specify How You Would Like us to Provide Access: