Personal Health Information Request Form

Request of Personal Health Information Procedure

Procedure #1

Access to Ambulance Report:

To obtain a copy of your file, you must:
1)  Complete the Request of Personal Health Information form and return the copy to our offices;

2)  Once your request has been received, the research will be made and the service will contact you to arrange an appointment;

3) You must report to our offices to obtain your copy. If this is not possible, you can apply by proxy (see procedure #2). Upon your arrival, you will need to show 2 pieces of identification including at least one with a picture;

4)  A fee of $25.00 is required and payable upon your arrival.

Procedure #2

Request through Proxy:

1)  Your legal counsel or your insurer can request a copy of your personal health information on your behalf by sending us our form duly completed by you. / To obtain the form, please contact us at 613.673.5139, at extension 224 or 226;

2) A fee of $25.00 is required plus fees for registered mail, and a cheque payable to the “United Counties of Prescott and Russell” must accompany the application;

3)  Upon receipt of this request, the emergency service will proceed with the research in order to send your information to your legal counsel or your insurer.

Complete the form