Common Forms

Download common forms here

Below you can download and view our common forms. If you are scheduling a transport, your insurer may require you (or your patient) to have a Physicians Certification Statement completed and signed by the appropriate person. Please check with your insurance to see what they require. These forms are for public use, we hope they help you with our service.

Notice Of Privacy Practices An online viewable version of our HIPAA Notice of Privacy Practices – UPDATED 1/11/14

HIPAA signature form– A downloadable version of our HIPAA signature form.

Physicians Certification Statement– A downloadable version of our PCS form, required for all BLS and ALS non-emergency medical transports

Authorization for PHI Use/Disclosure– The form to authorize a disclosure to a third party of your protected health information.

Request for PHI Accounting– The form to authorize an accounting of disclosures of your protected health information.

Request for PHI Confidential Communications– The form to request confidential communications of your protected health information.

Patient Request for PHI Restriction– The form to request protected health information be restricted.

Note- All authorizations and requests are subject to approval by the HIPAA Privacy and Compliance officer. Please note, if you are a power of attorney for a patient requesting records, you will need to provide a copy of the power of attorney form in order to obtain records. Patients may be asked to provide ID proving their identity. Please contact HIPAA Officer Nathan Harig with any questions using the form below.

[contact-form-7 id=”1658″ title=”HIPAA Form”]

If you are looking for an application for our annual ambulance subscription drive, please note that you can now purchase and renew subscriptions online.

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