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2. 
4. First Name
5. Last Name
7. Company (if applicable)
9. Address1
11. Address2
13. City
14. State
15. Zip
17. Phone #
19. Information Requested (i.e. fire report, fire prevention records, etc.)
    Note - A “Patient Request for Access” form should be completed for EMS record requests. EMS records are protected under HIPAA and will only be given to the patient or patient’s guardian if the patient is a minor. Valid picture ID is required to obtain medical records.
21. Date / Time / Location of Incident
23. Incident Number(s) (if known)
25. A response to most requests will be made within five business days.
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32. 1. Receive an email copy of this form.
33. Email address

    This field is not part of the form submission.

34. Submit

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