Danville Fire Department
Patient request for access
Danville Fire Department and Center Township / Danville
Ambulance Service
Patient Request for Access Form
Patient Name: ____________________________________ Date:
Address: _______________________________________________________________
City: ______________________ State: ______________ Zip Code:
Social Security No.: ________________________________
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 ____________