How can a records retrieval company, insurance company, law firm or attorney’s office, or any other business that requests records with a signed patient HIPAA authorization obtain patientMEDICAL AND/OR BILLING records?
Georgetown Fire Department utilizesChartswap.com, where you can register or sign-in as a Requestor to inquire about obtaining the needed documents. (Account Name: Georgetown Fire Department)
**Please note that while the majority of the form is fillable, wet signatures and initials are still required. You will need to print the form to complete it.**
HIPAA laws will be obeyed & enforced regarding protected health information (PHI). The following is required to obtain your medical record:
For obtaining your own PHI, a valid state or federally issued photo ID must be presented by the patient with a completed Authorization (above).
For obtaining another person’s PHI, a valid state or federally issued ID must be presented, along with proof of legal authority (health care Power of Attorney) with a completed Authorization (above).
For obtaining a minor’s PHI, a valid state or federally issued ID must be presented, along with the minor’s Birth Certificate and a completed Authorization (above).
For obtaining a deceased person’s PHI, a valid state or federally issued ID must be presented, Death Certificate, and a Letter Testamentary, Letter of Administration, or other document establishing the requester as the Personal Representative must be presented.
We understand that it can be difficult to pay a medical bill and are happy to offer up to a 12-month payment plan option. Please call 877-602-2060 for more information.
We are sensitive to those struggling financially and are committed to treating all patients regardless of their situation.
Individuals who can demonstrate financial hardship and would like to be considered for a reduction in the fees associated with ambulance treatment and/or transport may completethis form electronicallyor submit to the Georgetown Fire Department email address email@example.com.
Independent information is requiredto support claims of financial hardship, which can include verification of expenses and income. The following are accepted documents to aid in this consideration:
Proof of income
Notarized Unemployment Statements; how long unemployed
Unemployment check stubs
Income Tax Return
Employer or Welfare Documents
Other documents that may be accepted for consideration include Financial Hardship Acceptance/Approval from other institutions (specific to the incident); or a letter from the applicant explaining circumstances, expenses, debts, and/or providing the specific circumstances which require financial assistance.
Upon receipt and review of the submitted documents, applicants will be contacted regarding the resolution. Applicants will continue to receive invoices during the application review process.