Request for Records

Patient Rights: As a patient, you have the right to access, copy or inspect your protected health information, or PHI, in accordance with federal law.  You may also have the right to request an amendment to your PHI, or request that we restrict the use and disclosure of it.  These rights are further described in our  Notice of Privacy Practices and in other policies which you may have upon request.

Please submit the request below and we will contact you when your records are ready to be picked up.

NOTE: All records must be picked up at the Putnam EMS Office, 100 Emergency Lane, Winfield, WV. You must show a photo ID when picking up your records.

To better allow us to process your request, please indicate the type of request you are making on this form: (check all that apply)

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