Medical Records Release Information
Please be aware that you will be required to upload a copy of identification or the and/or the following documentation when submitting this form:
Patient: fill out the request authorization form and upload a copy of your photo identification.
Minor child: fill out the request authorization form, and upload both a copy of your identification AND a copy of the minor’s birth certificate.
Legal guardian of patients 18+: fill out the request authorization form, if the patient is not their own legal guardian, a copy of proof of power of attorney must be uploaded.
Deceased patient: fill out the request authorization form, a copy of the death certificate and proof of power of attorney must be uploaded. A valid photo ID matching the patient’s name and date of birth on the death certificate may also suffice.
Law Enforcement: fill out the request authorization form, and upload a subpoena, HIPAA release form, or written administrative request on your agency’s letterhead. Be sure to include your name, title and agency, patient name and DOB, what information you need (i.e. crew names, destination or the complete Patient Care Report). Also indicate that you need this for an active investigation.
Attorneys: fill out the request authorization form, upload a Qualified Protective Order or HIPAA release form signed by patient or other legal representative.
