PCR Request Form 102721

Brewster Ambulance Service is committed to maintaining the privacy of health information we obtain in the course of patient evaluation and treatment. Patient Care Reports (PCR) are considered confidential medical records and subject to the Health Insurance Portability and Accountability Act (HIPAA) and various privacy laws. Patient Care Reports are maintained in a secure manner, and may be released upon request to the patient named in the report or to other verified individuals or entities with a legal right to view the contents.

Patient Information

Patient Name: ________________________________________ Date of Birth: _________________________

Home Address: ________________________________________ City / State: _________________________

Incident Address: _______________________________________ City / State: _________________________

Date of Incident(s): ______________________________________ Email: ________________________________

Authorized Party’s Information

Name of Requestor: _____________________________________ Phone: ________________________________

Company / Agency: _____________________________________ Email: ________________________________

Address: ______________________________________________ City / State: ____________________________

Relationship to Patient: [ ] Parent of Minor [ ] Legal Guardian [ ] Patient Authorized Representative

[ ] Executor/Administrator of Estate [ ] Power of Attorney [ ] Other: ______________________________

** You MUST provide a copy of the legal authority you have to make medical decisions for the patient listed on the report. **

[ ] Law Enforcement Administrative Request. In accordance with 45 CFR 164.512(f)(1)(ii)(C), the information requested is relevant and material, specific and limited in scope, and de-identified information cannot be used.

Format of Record Release

[ ] In Person [ ] Mail [ ] Email [ ] ChartSwap

Authorization

By submitting this form, I authorize Brewster Ambulance Service, Inc. to release this Patient Care Report. As the patient, if I am authorizing the release of my medical record to the representative noted above, I understand that the release only pertains to the disclosure of the record described herein. This authorization shall expire immediately after the disclosure. I understand and agree that requests for reports in electronic form via email may not remain confidential due to the potentially unsecure nature of email transmission.

Patient Signature: _______________________________________________ Date: _____________________

Other/Authorized Requestor: _______________________________________________ Date: _____________________

Substantiating Information

Requests must include a good quality photo of the patient’s valid (unexpired) government issued photo ID (Driver’s license, Passport, Military ID, etc.) that clearly shows the signature. In cases where patient has not signed the request, the requestor must submit proof of relationship (e.g. minor child’s birth certificate, power of attorney) or law enforcement request. If patient is deceased, include a copy of death certificate or letters testamentary or letters of administration.