- Download a copy of the New York State Office of Court Administration Form 960: “Authorization to Release Health Information Pursuant to HIPAA”
- The OCA 960 is also available in paper form from our main offices at 40 Tobey Road (Pittsford). You may obtain this form in person or by mail by contacting our office.
- Complete the form, including ALL boxes (if an area of the form does not apply, simply put an X or dash – in that field).
- In Box 7 write: Pittsford Volunteer Ambulance, 40 Tobey Rd, Pittsford, NY 14534
- In Box 8 indicate to whom and at what address you wish the PCR to be sent.
- To receive a copy of a medical record via USPS or by email, we must verify your identity before we send any medical records in order to protect your privacy.
- Sign the OCA 960 Form before a Notary Public and have the Notary sign and stamp the form as near as practical to your signature on the bottom of the form. Then send the original form to us via U.S. Mail:
- Pittsford Volunteer Ambulance
- ATTN: Custodian of Medical Records
- 40 Tobey Road
- Pittsford, NY 14534
- To receive a copy of a medical record in person at our headquarters at 40 Tobey Rd (Pittsford):
- Call or email our Custodian of Medical Records to make an appointment (contact info below).
- Bring a government-issued photo ID and any other required documents (see below for special cases) with you along with the completed OCA 960 Form.
- If you are requesting a PCR on behalf of a family member, we will need some additional verification:
- If your family member has passed away, in addition to the OCA 960 Form we will need a copy of a Court determination of Executor of that patient’s estate. We will only be able to release that record to the Executor of the patient’s estate as established by a Court.
- If you are a parent of a minor child (under age 18) you may obtain the PCR by indicating on the OCA 960 Form in Box 12 and 13 your name, relationship, and your authority to sign on behalf of the patient (parent or legal guardian).
- In the case of legal guardianship, we may need additional information to assure that relationship, particularly if your last name differs from the child’s.
- If your family member is otherwise incapacitated due to a medical condition and is unable to sign for themselves, we would need a copy of a Durable Power of Attorney that allows us to release the PCR to you, along with the signed OCA 960 Form.
We have the capability of sending a copy of the PCR via encrypted electronic mail. If you should desire it to be sent in this manner, please provide us with an electronic mail address when you make your request, and be sure to indicate that you prefer email delivery over U.S. Mail. We will not fax PCRs due to the difficulty of ensuring secure delivery.
If you have a law firm representing you on a matter involving an encounter with EMS, your attorney will ask you to complete an OCA 960 and send it to us with an accompanying letter from that firm. This usually will suffice for release of a PCR to the law firm, to accompany your litigation.
If you have any questions about this process, please contact our Custodian of Medical Records by email at firstname.lastname@example.org or by telephone at 585-385-2401.