Public Records Request Online Form

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Mescal-J6 Fire District

Public Records Request Form

Required fields are marked (required).

REQUESTOR INFORMATION

This section completed by Requestor or District Representative (if phone request):

Date of Request (required)

Full Name (required)

Email (required)

Phone Number (required)

Mobile Number

Address (required)

City (required)

US States (required)

Zip (required)

How would you like to receive your record? (required)

Mail

In-Person

Other (Please describe below)

PLEASE NOTE: SOME FORMS OF RECORD TRANSMISSION MAY INCUR A FEE. MORE INFORMATION IS AVAILABLE ON PAGE 3. IF ANY FEES ARE INCURRED, PAYMENT MUST BE RECEIVED PRIOR TO ANY RECORDS BEING RELEASED.

If records are to be mailed, please include mailing address below (if different from above):

DOCUMENT DETAILS:

Is this request for a commercial purpose? (required)

Yes

Is this request for a minor? (required)

Yes

Please provide specific details of your request. (required)

Note: According to the Health Insurance Portability Accountability Act (HIPAA), Mescal-J6 Fire District is not permitted to disclose and/or release medical information without a signed HIPAA release form from patient (or patient’s properly designated representative). Mescal-J6 Fire District may require proof of identity for release of medical information. Third Parties requesting a patient’s medical record must attach one of the following: 1.) a notarized HIPAA form signed by patient; or 2.) a court order signed by a judge authorizing release.

Name of Patient: (required)

Date/Time of Incident

Date (required)

Time (required)

Address of Incident: (required)

Additional Information (if applicable):

Public Records Request Online Form

Public Records Request Form

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REQUESTOR INFORMATION

DOCUMENT DETAILS: