Incident Report Request - printable

INCIDENT REPORT OR MEDICAL RECORD REQUESTS CAN ALSO BE SUBMITTED ONLINE:   

Please refer to the online submission page - Click HERE.

However, if you prefer to complete and print out, see the option below.

This form can be printed out and completed to request information on an incident or to request medical records should you chose not to utilize our online submission form.  Please note that all medical record requests will require a HIPAA release form.  Prior written consent is required for medical information that pertains to other patients.

Additional documentation including a picture ID may be required before your request is processed.

Cost:

Medical Incident Reports:  Paper copies, $5 for the first page, $.41 per page for pages 2 through 50, and $.30 per page for pages 51 and higher.  Electronic copies $15.

Fire Incident Reports - Paper copies, $15 for the first ten pages, $1 per page for pages 11 and higher. Total cost will be determined once request is received.   Electronic copies, $15.

Reports will be forwarded once payment has been received and any additional documentation requirements have been met.

Completed requests can be emailed to fireadmin@hudsonnh.gov

For additional information please contact Fire Administration at 603-886-6021.