Request Records — Twin Township Ambulance

In a medical emergency, call 911. This form is for requesting copies of records only.

Fields marked * are required. For a medical record (patient care report), you’ll be asked for patient details and, if you have it, a signed authorization — this speeds up release under HIPAA.

What are you requesting? *

Your relationship to the patient *

Your name *

Email *

Phone

Organization (firm / insurer / agency, if any)

Patient & record details

Patient name *

Patient date of birth

Date of service (from)

Date of service (to)

Run / incident # (if known)

Signed authorization (PDF/image, optional)

A HIPAA-compliant, signed release speeds things up. We may still need to verify identity.

Photo ID (image/PDF, optional)

What records do you need? *

How should we deliver it? *

Mailing address *

I certify that the information above is accurate and that I am the patient or otherwise authorized to request these records. *

How it works

Submit this form — you’ll get a reference number by email.
We verify identity/authorization (medical records).
We prepare the records and deliver them your chosen way.

Prefer to call? (810) 634-1001

Email: office@twinems.org