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Patient Request for Access to Protected Health Information

  1. 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.
  2. Request for Access to PHI
    Please provide me with a copy of my EMS Patient Care Report (PCR)
  3. Specify How You Would Like Us to Provide Access
    Please complete all information that applies and fill out the requested information where indicated
  4. Mail
    Please send a copy of my PHI to me at the following address
  5. Email
    Please email a copy of my PHI to fhe following email address
  6. Other Parties
    Please transmit a copy of my PHI to the following party at the following mailing address or email address
  7. In person
    I would like to inspect a copy of my PHI at Jackson Hole Fire/EMS place of business during normal business hours
  8. Electronic Signature Agreement
    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
  9. Requestor Information (if requestor is different from patient)
  10. Authorization To Release Protected Health Information

    If you are requesting this on behalf of someone else please send a signed HIPAA release to

  11. Leave This Blank:

  12. This field is not part of the form submission.