Do I need a notary for the Patient Request for Access to Protected Health Information?

No. This request is signed and dated without a notary. A request to transmit records to another party must also be in writing and signed.

Who can request access to protected health information?

The patient or an authorized representative may request access. The form asks for patient information and, if the requestor is different from the patient, the requestor's name and relationship to the patient.

What information does the form ask me to provide?

It asks for patient and requestor details, a description of the information requested, and how you want to access it. Options include a copy by mail or email, transmission to another party, or inspection.

Bellmawr, MT · Camden County

No notary required

Patient Request for Access to Protected Health Information

Patients or their authorized representatives use this form to request access to protected health information held by Bellmawr Fire Department's Division of EMS.

What this form is

This form lets a patient or authorized representative request to inspect or receive a copy of protected health information maintained by Bellmawr Fire Department's Division of EMS. It asks for patient and requestor details, the records requested, and how access should be provided, including mailing, email, transmission to another person, or inspection. The form does not state a submission deadline or where to send the request.

Who needs it

A patient or authorized representative who wants to inspect, receive a copy of, or transmit the patient's protected health information should complete this form.

How to submit it

Submit it to the city department named on the form; check the city website for current contact details.

About notarization

This request is signed and dated without a notary; requests to transmit records to another party must also be in writing and signed.

How to submit this form

1
Download The Form
Download the Patient Request for Access to Protected Health Information form.
2
Complete The Request
Provide patient and requestor information, describe the information requested, and select how you want to access it.
3
Sign And Date
Sign and date the request. If asking to transmit information to another person, identify that person and where the information should be sent.
4
Confirm Submission Details
The form does not specify where to send it; check the city website for current contact details.

Frequently asked questions

Do I need a notary for the Patient Request for Access to Protected Health Information?: No. This request is signed and dated without a notary. A request to transmit records to another party must also be in writing and signed.
Who can request access to protected health information?: The patient or an authorized representative may request access. The form asks for patient information and, if the requestor is different from the patient, the requestor's name and relationship to the patient.
What information does the form ask me to provide?: It asks for patient and requestor details, a description of the information requested, and how you want to access it. Options include a copy by mail or email, transmission to another party, or inspection.
How do I submit the Patient Request for Access to Protected Health Information?: The form does not give a submission address or method. Submit it to the city department named on the form; check the city website for current contact details.

Need something notarized?

This Patient Request for Access to Protected Health Information doesn’t need a notary — but if you have another Bellmawr form that does, a commissioned online notary can help.