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HIPAA Form/Ambulance Report

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  3. 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.

  4. To better allow us to process your request, please indicate the type of request you are making on this form: *

  5. (Photo ID Required)

  6. If client Unable to Sign

  7. (Representative)

  8. Leave This Blank:

  9. This field is not part of the form submission.