Patient Care Record Requests

 

Patient care records are considered confidential and are protected by privacy laws. To request a medical record, please submit an Authorization for the Disclosure of Protected Health Information form.

 

Required:

 

• A legal photo ID that also contains your signature (i.e., Driver’s License, State Issued ID, Military ID, Passport, or City/State/Federal Employment ID Card)

 

For Legal Designee(s) of a Patient:

• All parents, guardians, and personal representatives must submit copies of official documentation evidencing their authority to act on behalf of the patient. (i.e., minor’s birth certificate, Medical Power of Attorney, Letters of Estate or Administration)

 

How to Submit the Form:

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Completed forms can be submitted in one of the following ways:

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• Requests can be made in person at the address below

• Email the form to medicalrecords@penderems.com

• Fax the form with a cover sheet to “Attn: Medical Records” at (910) 675-9169

• Send the form via US mail to:

Pender EMS & Fire, Inc.

Attn: Medical Records

14388 NC Hwy 210

Rocky Point, NC 28457

Law Offices:

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Attorneys requesting records may go to Chart Swap and look for records under “Pender Volunteer EMS and Rescue Inc”. For additional assistance, you can reach out to the Client Relations team (800-948-7991) at EMS Management & Consultants.

 

Judge Signed Papers:

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Judge signed papers (court orders, subpoenas, warrants, etc.) allow for release of patient care records without other documentation.