This form is intended for use by EMS system providers to request patient follow-up information.
- You may ONLY request information for patients whom you provided prehospital care for the current illness or injury.
- You may not request information for your own family members, even if you provided prehospital care for them.
- You may not disclose, share or discuss any patient outcome information provided to you with others who were not directly involved in the case.
- Any information provided is solely for Professional Standards Review Organization (PSRO) purposes and remains the property of the MCA. It may not be disclosed in any way. Any disclosure is a violation of federal and state confidentiality laws and is a protocol violation subject to disciplinary action and potential legal charges.
- Due to the number of patient encounters and the number of EMS providers in the MCA system, we ask that you please limit requests to unique situations and patients having suffered serious injury or illness.
- Please allow up to two weeks for a reply. Prior to gathering outcome information, we must confirm a direct patient relationship. Some information may not be available.