Release of Patient Care Report
Authorization for Release of Protected Health Information
Washington Ambulance Association, Inc. can only release protected health information to authorized personnel. If you wish to obtain a copy of a patient's ambulance call care report please note the following:
Federal and state law strictly limits who may obtain
your confidential patient care report.
If you wish to request your patient care report, please download and print this form, complete it, sign it, and either send it as a scanned document via email or mail it (recommended via certified mail). The authorization form must be signed by the patient unless the patient is not capable of signing or is deceased. Should the patient be incapable of signing the authorization on his/her own behalf, the form may be signed by a Guardian or Health Care Proxy. Proof of Durable Power of Attorney that includes the power to make health care decisions (Health Care Proxy) or proof of guardianship is required for verification. In the case of a patient that is deceased, the authorization may be signed by his/her spouse or other next of kin or his/her executor.
Private attorneys seeking patient run reports in conjunction with litigation must submit a request in writing, on company letterhead, which must include the following information: incident date, incident location, approximate time of incident, and patient's name. A signed "Authorization for Release of Protected Health Information" must be attached to the request letter.
Please contact us to discuss the circumstances under which we can release a patient care report to law enforcement.
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