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2. Please ensure that you have included a copy of the requestor's government issued ID. Red, White and Blue Fire Protection District will not release records without proper identification. For releases other than to the patient, legal documentation must be submitted to demonstrate parental right, legal guardianship, etc.
4. Patient First Name
5. Patient Last Name
7. Patient Address
9. Patient Date of Birth
   Patient Date of Birth
11. City
12. State
13. Zip Code
15. Patient Phone Number
16. Patient Email
18. Right to Request Access to Your Protected Health Information (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 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. We may also charge you a reasonable cost-based fee for providing you access to your PHI, subject to the limits of applicable state law.
20. Request for Access to PHI
    Please describe the PHI that you are requesting access to with as much specificity as possible. Specify dates of service and other details that will allow Red, White, and Blue Fire Protection District to accurately and completely fulfill your request.
24. Specify How You Would Like us to Provide Access
    Please select all that apply and fill out the requested information, where indicated. Options including by mail, email, or in person.
26. Please provide me with a copy of my PHI by mail.

    1. Yes
    2. No

    If yes, fill out address and format in the space provided.
28. Address
30. City
31. State
32. Zip Code
34. Format (paper copy, digital copy on a disc, etc.)
38. Please provide me with a copy of my PHI by Email.

    1. Yes
    2. No

    If yes, including email address in the space provided.
40. Email Address
    PHI will be emailed to the email address provided in a PDF format.
44. Please transmit a copy of my PHI to a designated party.

    1. Yes
    2. No

    If yes, fill out information about Designated party in space provided.
46. Format (Paper, PDF, Digital Copy, etc.)
48. Designated Party
50. Address
52. City
53. State
54. Zip Code
56. Email Address
57. Fax Number
61. I would like to inspect a copy of my PHI at Red, White & Blue Fire Protection District’s place of business.

    1. Yes
    2. No

    Red, White & Blue Fire Protection District will arrange a convenient time and place for you to inspect a copy of your PHI during normal business hours.
65. Signature of Requestor
66. Request Date
    Request Date
68. Requestor Information (If requestor is different from patient)
70. Requestor First Name
71. Requestor Last Name
73. Relationship to Patient (parent, legal guardian, etc.)
75. Address
77. City
78. State
79. Zip Code
Leave This Blank:


80. Print Only

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