For a copy of a BLS Patient Care Report (PCR), please submit the form below.

All information submitted below MUST match the information on the OCA Official Form No.:960

For questions, please email our Custodian of Records or call 845-623-6387 Ext. 2.

Most requests are handled within 45 business days.

All information submitted below is confidential and is only shared with the Custodian of Records.

Indicates Required Field

Your Name:
Your Title:
Your Phone Number:
Your Email: A copy of this submission will be automatically sent to this email.
Name of Law Firm or Agency Requesting Records:
Address of Requesting Law Firm/Agency:
Phone Number of Requesting Law Firm/Agency:
Patient's First Name:
Patient’s Last Name:
Patient’s Date of Birth:
Patient's Social Security Number:
Patient's Address:
Patient's Address (City):
Patient's Address (State):
Patient's Address (Zip Code):
Date of Incident/Loss:
OCA Official Form No.:960/Subpoena: Please upload the completed and signed OCA Official Form No.:960 or subpoena here.		Add files...
Name of Law Firm/Agency Where Records Will be Sent:
Whose Attention Should the Records be Mailed to?:
Law Firm/Agency Address:
Law Firm/Agency Address (City):
Law Firm/Agency Address (State):
Law Firm/Agency Address (Zip Code):
Request Submitted:		07/16/2025 1339