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:

Incident Report - Medical: $15.00

Incident Report - Fire: $15.00 first 10 pages, $1.00 each additional page. Total cost will be determined once request is received. 

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.