Incident Report or Medical Records Request - online submission

This form can be used to request information on an incident or to request medical records.  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.

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