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2. SECTION 1 (Must be completed for all requests)
4. First Name*
5. Last Name*
6. Today's Date*
8. Address*
10. City*
11. State*
12. Zip Code*
14. Phone Number*
15. Email Address*
17. Information Requested:*

    1. Fire Report
    2. Medical Report
    3. Other
19. Location of Incident*
21. Nature of Incident*
22. Date of incident (MM/DD/YY)*
24. Reason for Request*
28. SECTION 2 (Must be completed for medical report requests)
30. Relationship to Patient
32. Patient's First Name
33. Patient's Last Name
34. Patient's Date of Birth
36. Is Patient Deceased?

    1. Yes
    2. No
    3. Unknown
37. Patient's Date of Death
39. Do you have one or more of the following medical release authorizations?

    1. Power of Attorney
    2. Living Will
    3. Release from person when living
    4. Certification by Circuit Court as sole heir/executor
41. If not related to the patient, indicate agency or organization affiliation giving you authority or cause to obtain records.
43. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
45. Electronic Signature*

    All medical documentation must be picked up in person by the requesting individual, and all appropriate supporting documentation and picture identification must be presented at that time unless other previously approved arrangements have been made.

Leave This Blank:


47. 1. Receive an email copy of this form.
48. Email address

    This field is not part of the form submission.

49. Submit

* indicates a required field