REPRESENTATIVE & GUARDIANSHIP REQUESTS
Requesting Records for Another Individual
To comply with HIPAA and state privacy laws, Acadian Ambulance requires verification of both the representative’s identity and their legal authority to access the patient’s medical records.
Choose the Category that Fits Your Request:
1. Parents or Legal Guardians of a Minor
If the patient is under the age of 18, the request must be made by a parent or legal guardian.
- Required: Completed Authorization Form signed by the parent/guardian.
- Required: Copy of the Parent/Guardian’s Photo ID.
- Required: Proof of Guardianship (e.g., Birth Certificate, Adoption Papers, or Court-Ordered Custody documents).
2. Deceased Patients (Next of Kin/Heirs)
If the patient is deceased, the request must be made by the Executor of the Estate or the legal next of kin.
- Required: Completed Authorization Form signed by the representative.
- Required: Copy of the Representative’s Photo ID.
- Required: Proof of Authority. This must be one of the following:
- Letters of Testamentary or Court-Appointed Executor papers.
- A copy of the Death Certificate AND our Sword Affidavit of Representative Authority if no formal estate has been opened.
3. Adults with Power of Attorney (POA)
If the patient is an adult who has granted you the right to handle their affairs, you must provide the POA document for review.
- Required: Completed Authorization Form signed by the POA.
- Required: Copy of the Representative’s Photo ID.
- Required: A copy of the Power of Attorney document.
CRITICAL CHECK: Does your Power of Attorney grant medical access? Per federal HIPAA regulations, a “General” or “Financial” POA is often insufficient. To be accepted, the document must specifically grant authority for healthcare decisions, medical care, or the release of medical records. If this language is missing, we cannot legally release the records to you.
Submission Checklist
To avoid delays, please ensure your submission package includes all three parts:
- Signed Authorization for Release Form
- Your Photo ID: A copy of the person signing the form (Driver’s License or State ID).
- Supporting Document: The document that proves your relationship or legal authority (Guardianship, POA, or Affidavit).
How to Submit
Submit all documents together as a single package to ensure faster processing.
- Email: medicalrecords@acadian.com
- Please include the patient name and date of service in the subject line
- Mail: Acadian Ambulance, Attn: Medical Records, P.O. Box 98000, Lafayette, LA 70509.
