Request for Medical Records

Font Size: + -

Feedback Print

Privacy Notice: This form is not submitted online. All information entered stays on your device until you download the PDF. No data is transmitted to the City until you submit the completed forms via email or mail.

Required Documents

1. Copy of Patient's Photo ID
2. Signed HIPAA Release Form

1. Requestor Information

Requestor Full Name *

Date *

Company / Organization (optional)

Relationship to Patient *

Email Address *

Phone Number *

Reason for Request *

Preferred Submission Method *

Billing Address Line 1 *

Billing Address Line 2 (optional)

City *

State *

ZIP Code *

2. Incident Details

Date of Incident * Add another date

Time of Incident (optional)

Incident Number (if known)

Incident Location (optional)

3. Patient Information

Patient Last Name *

Patient First Name *

Patient Middle (optional)

Patient Date of Birth *

Patient Phone (optional)

4. Additional Information

Special Instructions or Notes (optional)

5. Confirmation

I will include Patient's Photo ID

I will include Signed HIPAA Release (mine or the provided form)

Note: You may use your own HIPAA authorization if provided by your attorney or organization.

1. Patient Information

Patient Last Name *

Patient First Name *

Patient Middle (optional)

Date of Birth *

Last 4 of SSN

Phone Number

Street Address

City

State

ZIP Code

2. Authorization - I Authorize Release Of:

All medical records related to the incident/treatment on the date(s) specified below

Specific records only (specify below)

Specific Records Description (if checked above)

Date of Service/Incident * Add another date

Fire Dept Incident Number (if known)

3. Release Information To:

Name of Person/Organization *

Relationship to Patient *

Mailing Address Line 1 (optional)

Mailing Address Line 2 (optional)

City (optional)

State (optional)

ZIP Code (optional)

4. Purpose of Disclosure (optional)

Personal use

Insurance claim

Legal matter

Continuation of medical care

Other Purpose (optional)

I understand that:

I have the right to revoke this authorization at any time by submitting a written request to Fullerton Fire Department, except to the extent that action has already been taken based on this authorization.
Once my information is disclosed pursuant to this authorization, it may be subject to re-disclosure by the recipient and may no longer be protected by federal or state law.
I have the right to refuse to sign this authorization and that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on signing this authorization.
I may inspect or obtain a copy of the information to be disclosed as provided in CFR 164.524.
A fee of $15.00 applies for copying and processing medical records.

5. Expiration

This Authorization Expires:

6. Signature

Signature of Patient or Personal Representative *

Date *

If Signed by Personal Representative

Fullerton, CA

01 How Do I...

02

03

Popular Services

Request for Medical Records

Request Form for Medical Records