Williamsport Volunteer Ambulance Service

Patient Request for Access to PHI Form

(Please print out, fill out all spaces below, and mail to address listed below.)

Patient Name: __________________________________________

Street Address: __________________________________________

City: _______________ State: _________ Zip Code: _________

Social Security #: ________________________ Last Date of Service: _________________

Patient Rights: As a patient, you have the right to access, copy or inspect your protected health information, or PHI, in accordance with federal law. You may also have the right to request an amendment to your 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 request you are making on this form: [check all that apply]

___ Access to simply review my health 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 health information.

Signature: _______________________________ Request Date: ______________

(Please return this form to)

WVAS, Privacy Officer

P.O. Box 102

Williamsport, MD 21795