EMS Patient Care Report Request

A copy of a patient care report is only available to the patient, assigned representative, parent/guardian, Medical Power of Attorney, executor or administrator of the patient's estate, and/or the Next of Kin listed on a Death Certificate. EMS Records are private and confidential. The information in a patient care report is protected under the Health Insurance Portability and Accountability Act (HIPAA). In order to release this information, we must have a completed Disclosure of Protected Health Information. Proper documentation must be included with your request:

• If you are the patient or assigned representative, the Disclosure of Protected Health Information  with yourself listed in the authorization section. This form must be notarized.
• If you are the parent/guardian of the patient who is a minor, Disclosure of Protected Health Information along with a copy of the birth certificate or insurance card that lists both the parent/guardian and the child.
• If you are the patient's Medical Power of Attorney (POA), Disclosure of Protected Health Information and a complete copy of the POA.
• If you are the executor or administrator of the patient's estate, Disclosure of Protected Health Information and a copy of that document.
• If you are the Next of Kin, Disclosure of Protected Health Information, a copy of the Death Certificate with the Next of Kin listed (must be same person who is obtaining report), your photo ID.

You may receive the EMS report through one of the following:

• Email - Email the notarized Disclosure of Protected Health Information request to emsreport@libertytwp.org
• Mail - Mail the notarized Disclosure of Protected Health Information to 7761 Liberty Rd. N Powell, Ohio 43065, Attention EMS Record Request.

Please call 740-938-2021 or email emsreport@libertytwp.org with questions