Form Center

2. Name
3. Email Address
5. Address
7. City
8. State
9. Zip Code
11. Phone Number
12. Date of Birth
14. Right to Request Access to Your PHI and Our Duties:
    You (or your authorized representative) have the right to inspect or obtain a copy of your protected health information ("PHI") that we maintain in a designated record set. If we maintain your PHI in electronic format, then you also have a right to obtain a copy of that information electronically. In addition, you may request that we transmit a copy of your PHI directly to another person and we will honor that request when required by law to do so. Requests to transmit PHI to another party must be in writing, signed by you (or your representative), and clearly identify the designated person to whom the PHI should be sent, and where the PHI should be sent. Generally, we will provide you (or your authorized representative) access to your PHI within thirty (30) days of your request. We may verify the identity of any person who requests access to PHI, as well as the authority of the person to have access to the PHI by asking the requestor to provide the patient's social security number, date of birth, legal authority to act on behalf of the patient (such as a power of attorney) or other information necessary to verify that the requestor has the right to access PHI. In limited circumstances, we may deny you access to your PHI, and you may appeal certain types of denials.
16. Request for Access to PHI
    Please provide me with a copy of my EMS Patient Care Report (PCR)
17. Date(s) of Service*
19. Address of Incident *
21. Specify How You Would Like Us to Provide Access
    Please complete all information that applies and fill out the requested information where indicated
23. Mail

    Please send a copy of my PHI to me at the following address

    1. Yes
    2. No
24. Mailing Address
26. City
27. State
28. Zip Code
30. Email*

    Please email a copy of my PHI to fhe following email address

    1. Yes
    2. No
31. Email Address
33. Other Parties

    Please transmit a copy of my PHI to the following party at the following mailing address or email address

    1. Yes
    2. No
35. Designated Party
36. Email Address
38. Address
40. City
41. State
42. Zip Code
44. Phone Number
45. Fax Number
47. Format (Paper, PDF
49. In person

    I would like to inspect a copy of my PHI at Jackson Hole Fire/EMS place of business during normal business hours

    1. Yes
    2. No
51. Date and Time Requested
53. Are you requesting this on behalf of someone else? *

    1. Yes
    2. No
55. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
57. Electronic Signature*
59. Requestor Information (if requestor is different from patient)
61. Authorization To Release Protected Health Information

    If you are requesting this on behalf of someone else please send a signed HIPAA release to tturner@tetoncountywy.gov. 

63. Name
64. Relationship to Patient
66. Mailing Address
68. City
69. State
70. Zip Code
Leave This Blank:


72. 1. Receive an email copy of this form.
73. Email address

    This field is not part of the form submission.

74. Submit Submit and Print

* indicates a required field