Williamsport Volunteer Ambulance Service

Patient Request for PHI Restriction Form

(Please print out, fill out spaces below, and mail to address at bottom)

Patient Name: __________________________________________

Street Address: __________________________________________

City: _______________ State: _________ Zip Code: _________

Social Security #: ________________________ Last Date of Service: _________________

Patient Rights: As a patient, you have the right to request restrictions to the uses and disclosures of your PHI. WVAS is not required to agree to any restrictions requested by the patient, however any restrictions agreed to by WVAS are binding on WVAS

Please detail your request for restricted uses and disclosures of your PHI below.

Signature: _______________________ Date: __________________

Mail to: Privacy Officer, WVAS; P.O. Box 102; Williamsport, MD 21795

FOR AMBULANCE SERVICE USE ONLY

DATE REC'D: ________________

REQUEST ACCEPTED: _____

REQUEST DENIED: _____

DATE: ________________

REVIEWING OFFICER ________________

DATE SENT TO PT ________________

COMMENTS: ______________________________________________________________