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2. First Name
3. Last Name
5. Date
   Date
7. Address
9. City
10. State
11. Zip Code
13. Phone Number
14. Email Address
16. Information requested:

    1. Fire Report
    2. EMS Report (individual requests must be completed in-person)
18. Location of Incident
20. Address
22. City
23. State
24. Zip Code
26. Nature of Incident
28. Date of Incident
    Date of Incident
29. Reason for Request
31. Verification of Identity

    Verification of Identity may be required. Personal healthcare information is protected and will only be released to:

    -the patient

    -a power of attorney

    -through a living will

    -Certification by Circuit Court as sole heir/executor

    
    

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33. 1. Receive an email copy of this form.
34. Email address

    This field is not part of the form submission.

35. Submit

* indicates a required field