• Patient Authorization to Use and Disclose Protected Health 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).

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

     JMiller@SouthBridgeEMS.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

  • Specify How You Would Like us to Provide Access:

  • 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.

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