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Park Forest Fire Department Patient Request for Access Form

  1. Fire Department
  2. 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.
  3. To better allow us to process your request, please indicate the type of request you are making:
    Check all that apply
  4. Leave This Blank:

  5. This field is not part of the form submission.