Patient Records Request
Each time an emergency medical services team has contact with a patient, they generate a “Prehospital Care Report” or PCR. This document outlines the EMS Provider’s assessment and any treatment that may have been rendered. The PCR is governed by a number of regulations, including the Health Insurance Portability and Privacy Act, or HIPAA. Because patient privacy is important to us and a matter of legal obligation, we have established safeguards and procedures to ensure that only authorized persons may receive PCRs.
If you are a patient or family member of a patient, and wish to obtain a copy of a PCR for an encounter with our service, the following procedure should be followed:
Download a copy of the New York State Office of Court Administration Form 960: “Authorization to Release Health Information Pursuant to HIPAA,” from the following web site:
The OCA 960 is also available in paper form from our ambulance base, located at 1 Tountas Ave Le Roy, NY 14482. You may obtain this form in person or by mail by contacting our office.
Complete the form, including ALL boxes (if an area of the form does not apply, simply put an X or dash – in that field).
In Box 7 write:
Le Roy Ambulance Service, 1 Tountas Ave Le Roy, NY 14482In Box 8 indicate to whom and at what address you wish the PCR to be sent.
Your identity must be verified before we will be able to fulfill your request, in order to protect your privacy. To receive a copy of a medical record via USPS or by email:
Sign the OCA 960 Form before a Notary Public and have the Notary sign and stamp the form as near as practical to your signature on the bottom of the form. Then send the original form to us via U.S. Mail:
Le Roy Ambulance Service
ATTN: Medical Records Request
P.O. Box 56
Le Roy, NY 14482
To receive a copy of a medical record in person at our ambulance base:
Call or email one of our chiefs at (585) 768-8612 or chief@leroyems.org to make an appointment.
Bring a government-issued photo ID and any other required documents (see below for special cases) with you along with the completed OCA 960 Form.
If you are requesting a PCR on behalf of a family member, we will need some additional verification:
If your family member has passed away, in addition to the OCA 960 Form we will need a copy of a Court determination of Executor of that patient’s estate. We will only be able to release that record to the Executor of the patient’s estate as established by a Court.
If you are a parent of a minor child (under age 18) you may obtain the PCR by indicating on the OCA 960 Form in Box 12 and 13 your name, relationship, and your authority to sign on behalf of the patient (parent or legal guardian).
In the case of legal guardianship, we may need additional information to assure that relationship, particularly if your last name differs from the child’s.
If your family member is otherwise incapacitated due to a medical condition and is unable to sign for themselves, we would need a copy of a Durable Power of Attorney that allows us to release the PCR to you, along with the signed OCA 960 Form.
We have the capability of sending a copy of the PCR via encrypted electronic mail. If you should desire it to be sent in this manner, please provide us with an electronic mail address and a phone number where you can receive a text message verification code when you make your request, and be sure to indicate that you prefer email delivery over U.S. Mail. We will not fax PCRs due to the difficulty of ensuring secure delivery.
If you have a law firm representing you on a matter involving an encounter with EMS, your attorney will ask you to complete an OCA 960 and send it to us with an accompanying letter from that firm. This usually will suffice for release of a PCR to the law firm, to accompany your litigation.
If you have any questions about this process, please contact one of our Chiefs, who serve as our HIPAA compliance officers, at (585) 768-8612 or chief@leroyems.org