Tri-Community Ambulance 

Proudly serving the residents of the Bergholz, Pekin, Sanborn and St. Johnsburg Fire districts since 1956!

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Requesting medical records from Tri-Community Ambulance Service, Inc.

If Tri-Community Ambulance Service, Inc. provided care for you or a loved one, and you now need a copy of their medical records, we would be happy to assist you with your request.  Tri-Community will need a few things from you to ensure we are compliant with the law and protecting your privacy.  If you are requesting medical records for yourself, we will have a HIPAA release form for you to take to a notary public and properly complete. This ensures we are not releasing your records in violation of any laws. If you are attorney represented, your attorney will guide you through the process.  You can learn more about HIPAA compliance by clicking here.

Thank you for your online medical records request.

Tri-Community Ambulance Service, Inc. will review your request and if there is anything else we need to process your request, we will be in contact. Tri-Community Ambulance Service, Inc. reserves the right to inspect all documents submitted to ensure they are within compliance with all local, state and federal laws. Tri-Community Ambulance Service, Inc. respects each persons privacy, and appreciate your understanding while we review all documentation submitted.

All request letters or attorney letter of representation letters MUST include the date of service and patient name so we may locate your records. Failure to include these pieces of data may result in your request being sent back for further information.

Please ensure we have a copy of your HIPAA (Health Insurance Portability and Accountability Act) release form. Without this form, we are unable to release your records for privacy and legal reasons. Once we have a copy of your HIPAA form, we will be happy to coordinate releasing your medical records to you. If you are picking up your records personally, valid government issued photo identification is required. If you are attorney represented, please have your attorney submit a letter of representation along with your HIPAA form so we may process their request on your behalf.

Please submit any request letters, attorney letter of representation letters and HIPAA release authorization forms to: [email protected]

CONFIDENTIALITY NOTICE -- This email inquiry form is intended only for the business use of the requestor and Tri-Community Ambulance Service, Inc. Unless otherwise indicated, it contains information that is confidential, privileged and/or exempt from disclosure under applicable law. If you have received this message, message string, or portions of this message in error, please notify the sender of the error and delete the message. Thank you.
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