Pre-Hospital Care Report Request

In New York, requesting ambulance medical records requires a signed and notarized HIPAA Authorization form (OCA Official Form No. 960). This form, or its equivalent, is a legal requirement for accessing a patient's protected health information (PHI) under both federal HIPAA regulations and state law.

To Request a Patient Care Record: All requests for medical records must be made in writing, signed and notarized. It should clearly specify Central Islip – Hauppauge Volunteer Ambulance Corps as the provider and that you are permitting the record to be released. Please include the information sought, a specific date range, photo identification, and the address of where the information should be sent.

If you are a parent or guardian requesting the record(s) of a minor, you MUST provide the above written request and Photo ID along with proof of guardianship via one (1) of the following documents:

• Child’s birth certificate
• Court document validating custody

Third Party Requests for Patient Records: If you are requesting the record(s) of someone else, you MUST provide the above written request and Photo ID along with:

• A signed and notarized Power of Attorney which lists the requester

If you are requesting the record(s) of someone who is deceased, you must provide the above written request along with the following:

• Photo Identification of the requester
• The patient’s death certificate
• The patient’s identifying information, such as date of birth and social security number
• A court document establishing the requester as executor or representative of the estate