Ambulance Report Form

Patient Request for Ambulance Report

Buffalo Grove Fire Department

Patient Request for Access Form

 

Patient Rights: As a patient you have the right to access, copy, or inspect your protected health information (PHI) in accordance with Federal Law. You may also have the right to request an amendment to you 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 which you may have upon request.

To better allow us to process your request, please indicate the type of requestyou are making on this form: [check all that apply]

Access to simply review my heath 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 PHI

Note: Records must be picked up in person with a photo ID corresponding to the above information and your Social Security Number must be provided.

Ambulance reports are not subject to the Freedom of Information Act.

 



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