Record Request | Susquehanna Township EMS

STEMS Medical Record Request

All Patient Health Care information is confidential and protected under Federal Law (HIPAA). Therefore Patient Care Records (PCR’s) cannot be released to any person or organization without the consent of the patient, or the patient’s legally authorized representative (unless authorized by law).

EMS Medical Records Request

I Requesting EMS Medical Records as:*
Patient Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Last Four Digits of Patients Social Security #*
Patient Address*
Street Address Address Line 2 City State ZIP Code
Contact Phone #*
Date of EMS Service*
MM slash DD slash YYYY
I would like my records to be:*
Email Address*
Enter Email Confirm Email

Please be aware that STEMS is not responsible for the security of your Email Account. Medical Records sent to your email address may be accessible by unauthorized parties. STEMS is not liable for information after it has been delivered.
Address*
Street Address Address Line 2 City State ZIP Code
Fax Number*
Our Business Office is located at 108 Short St. Harrisburg Pa 17109 and is Open Monday through Friday 8am to 4pm. Please Contact us at 717-545-0842 to confirm a time to pick up your records.
I understand that I have the right to revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing and present my written revocation to the STEMS Health Information Officer. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that this revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. This authorization is effective as of the date set forth in this document. I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I understand that I may inspect or copy the information to be used or disclosed, as provided by federal patient privacy regulations. I understand that any disclosure of information carries with it the potential for information disclosed pursuant to this authorization to be re-disclosed by the recipient and no longer protected by federal patient privacy regulations. If I have any questions regarding this disclosure of my health information, I may contact the compliance and privacy officer at 108 Short Street Harrisburg Pa 17109. I understand the nature of this authorization. The federal privacy regulations referred to in this document may be found at 45 CFR160 and 164.
Acknowledgement of HIPAA statement and Authorizing Signature*
By entering your name, you are confirming that you are legally permitted to request and receive confidential and Federally Protected Health Information.
Medical Records Retrieval and Reproduction Fee*
Price:
Under 42 Pa.C.S. §§ 6152 and 6155, Health Care Providers and Facilities are permitted to charge for the expense of retrieving and reproducing Medical Records.
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