Required fields are marked with asterisks (*)

Ambulance Call Report (ACR) Request Form

All requests for copies of Ambulance Call Reports must be submitted on this form.

Hard copies of completed forms should be forwarded to:

County of Essex, Privacy Officer,

360 Fairview Avenue West,

Essex, Ontario N8M 1Y6,

Phone: 519-776-6441, Fax: 519-776-4455, E-mail: PrivacyOfficer@countyofessex.ca

Essex-Windsor EMS Professional Standards Division,

360 Fairview Avenue West,

Essex, Ontario N8M 1Y6

Phone: 519-776-6441 Fax: 519-776-1254.

Proof of identification and/or legal authorization to release information may be required for release of these records.

As of January 1, 2013, a service of $75.00 per ACR will be payable to the Corporation of the County of Essex before delivery of the requested document(s).

Health Information Custodians and Law Enforcement Agencies are exempt from the service fee.

Name of Firm or Organization Requesting the ACR

Last Name:

First Name:

Address (Street/Apt. No./P.O.Box/RR No.)

City/Town:

Province:

Postal Code:

Telephone Number (Day)

Telephone Number (Evening)

Email Address:

Request for:

I am a representative of the individual to whom this request pertains and have been explicitly authorized by that individual to obtain a copy of the requested ACR. (Release Authorization signature required).

I am requesting disclosure of an ACR that relates to myself. (Release Authorization signature required).

I am a Health Care Practitioner and require disclosure of the requested ACR for the purpose of providing health care to my patient. Explicit consent of my patient cannot be obtained in a timely fashion. (Release authorization signature not required).

I am a representative of the Ministry of Health and Long-Term Care and require disclosure of the requested ACR for purposes relating to the discharge or exercise of EMS staff duties or powers under the Ambulance Act. (Release authorization signature not required).

Other (Release Authorization signature required)

Authorization for Release of ACR

Date of the Ambulance Call Report

Name of Person to which the ACR pertains (patient name)

Location (address or vicinity) where the call and pickup took place:

Time that the call took place (indicate AM or PM)

Preferred Method of Access to Records

Information will be picked-up at Essex-Windsor EMS Office located at 360 Fairview Avenue West, Essex, Ontario (Authorization and/or Proof of Identification Required)

Send information to an alternate address. (Specify below and Authorization Required)

Send information to the Contact Person listed above. (Authorization Required)

Send information to the patient directly. (Address verification required)

Mailing Address

Email Address

Please add any supporting documentation (Signed Legal Authorization, POA etc.)

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Allowed extensions pdf, doc, docx, xls, xlsx, jpg, jpeg, gif, png, tif

By signing this Authorization, I am permitting the disclosure and sharing of my health and medical information contained on an ACR in the possession of Essex-Windsor EMS to the individual or organization specified as the Requester above.

Clear

Signed on Date:

Title of Legal Representative (If signed by legal representative, please provide supplemental proof of authorization)

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Forms

Ambulance Call Report (ACR) Request Form

Authorization for Release of ACR