Patient Care Request
DIRECTIONS FOR REQUESTING PATIENT CARE REPORTS
If you are the patient:
Fill out the form below to request your patient care report. Please include all requested information including name, address and the reason for the request. The form must be signed by the patient.
If you are the patient’s surrogate, i.e., attorney, power of attorney, parent, guardian, or spouse:
Fill out the form below for the patient care report. Please include all requested information including the name of the patient, your name, address and reason for the request, and your position of surrogacy. The form must be signed by the surrogate.
All requests for patient care reports must be mailed to:
Echo Hose Ambulance
PO Box 213
Shelton, CT 06484
ATTN: Billing Department
A copy of a valid driver’s license or another picture form of government ID must be included with all requests. The ID must match the name of the person requesting the documentation.