Bellbrook, OH · Greene County
Patient Request for Access
Bellbrook patients use this form to request access to, copies of, or other actions involving their protected health information held by the Fire/EMS Department.
What this form is
Use this form when asking to review or obtain copies of your health information, or to review and potentially request an amendment, an accounting of disclosures, or restrictions on use and disclosure. It asks for the patient's name, contact details, Social Security number, last date of service, the request type, signature, and request date. The form describes patient rights but does not state when the city requires its use.
Who needs it
A patient seeking to review or obtain copies of health information, or request an amendment, accounting, or restriction, can use this form.
How to submit it
Submit it to the Bellbrook Fire/EMS Department; the form does not list an address or other submission method, so check the city website for current contact details.
About notarization
This form does not require notarization; the patient signs and dates the request, with no sworn attachment or related notarized step stated.
How to submit this form
- 1
Download the Form
Download the Patient Request for Access form.
- 2
Complete the Patient Details
Enter the requested patient information, including the last date of service.
- 3
Select Your Request
Check all request types that apply.
- 4
Sign and Date the Form
Sign and enter the request date; the form does not list required attachments.
- 5
Submit to the Department
Submit the form to the Bellbrook Fire/EMS Department; check the city website for current contact details.
Frequently asked questions
- What can I request with the Patient Request for Access form?
- You can request to review or obtain copies of health information, or review and potentially request an amendment, an accounting of disclosures, or restrictions on use and disclosure.
- What information does the form ask for?
- It asks for your name, date, address, Social Security number, last date of service, the type of request, your signature, and the request date.
- Do I need a notary for the Patient Request for Access form?
- No. The patient signs and dates this form; it does not state that a sworn attachment or related step needs notarization.
- How do I submit the Patient Request for Access form?
- Submit it to the Bellbrook Fire/EMS Department. The form does not provide an address or submission method; check the city website for current contact details.