Patient Request for Access to Protected Health Information

Step 1 of 3

Patient Name(Required)

First Last

Phone

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Birth(Required)

Email(Required)

Enter Email Confirm Email

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 A-TEC Ambulance, Inc. 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.

Handling Checkbox

Please provide me with a copy of my PHI

Please email a copy of my PHI to the following email address in the specified format

Please transmit a copy of my PHI to the following party at the following mailing address or email address in the specified format

I would like to inspect a copy of my PHI at A-TEC Ambulance's place of business (A-TEC will arrange a convenient time and place for you to inspect a copy of your PHI during normal business hours).

Please provide me with a copy of my PHI

My Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Desired Format (paper copy, digital copy on a disc, etc.)(Required)

Please email a copy of my PHI to the following email address in the specified format

My Email(Required)

Enter Email Confirm Email

Format (PDF, Word, etc.)

Please transmit a copy of my PHI to the following party at the following mailing address or email address in the specified format

Designated Party(Required)

First Last

Transmit PHI to:(Required)

Mailing Address

Email Address

Designated Party's Mailing Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email(Required)

Enter Email Confirm Email

Signature of Requestor(Required)

Request Date(Required)

Requestor is the patient

Requestor Information

Name(Required)

First Last

Relationship to Patient (parent, legal guardian, etc.)(Required)

Requestor Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

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