Enforcement Agency Requests

Law Enforcement Requests

Released From Mecklenburg EMS Agency 4425 Wilkinson Blvd Charlotte, NC 28208 704-943-6000 legalrequest@medic911.com
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Incident Date*

MonthDayYear
Date
Incident Address*

Street Address

Street Address Line 2

CityState

Zip Code
Is this for an investigation?*

YesNo
Requested Information*
Release Information to the Following
Name*

First NameLast Name
Organization*
Phone Number*
Fax Number
Email Address*
Delivery Method*
Release only valid for 1 year with signature
Report Number
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Consent*

I understand that this release is valid when I sign it and that I may withdraw my consent to this release at any time to legalrequest@medic911.com. I also understand that my information may be transmitted unsecured, and that such transmission may carry some risk of unauthorized access.
I attest that the use or disclosure of PHI that I am requesting is not for a purpose prohibited by the HIPAA Privacy Rule at 45 CFR 164.502(a)(5)(iii) because of the following (check one box)*

The purpose of the use or disclosure of protected health information is NOT to investigate or impose liability on any person for the mere act of seeking, obtaining, providing, or facilitating reproductive health care at issue was not lawful under the circumstances it was providedThe purpose of the use or disclosure of protected health information IS to investigate or impose liability on any person for the mere act of seeking, obtaining, providing, or facilitating reproductive health care at issue was not lawful under the circumstances it was provided
I understand that I may be subject to criminal penalties pursuant to 42 U.S.C. 1320d-6 if I knowingly and in violation of HIPAA obtain individually identifiable health information relating to an individual or disclose individually identifiable health information to another person.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Law Enforcement Requests

Release Information to the Following