For Records Requests

(THE BELOW IS JUST AN EXAMPLE) Requests for Patient Healthcare Information (PHI) that are authorized under HIPAA shall include the following:

• A properly signed and executed LifeCare Ambulance Request to Access Own PHI or other appropriate release.
• The appropriate fee, in accordance with the current fee schedule, and/or postage (if the requested records are to be mailed) for obtaining copies of the requested records. Only cash or check are accepted. Checks shall be made payable to “LifeCare Ambulance”
• Requests over the phone for PHI cannot be honored under law.
• The requestor must be present and have valid identification.
• If the patient is a minor, a parent or legal guardian may obtain a copy of his or her medical record.

Patients and parties representing them may have reason to request a copy of the written run report for a call. To request a copy of a run record please fill out and return our release form with a copy of a valid government photo ID to:

• LifeCare Ambulance
  640 Cleveland Street
  Elyria, OH 44035