Request Healthcare Records

Use the online form below to obtain a healthcare information report.


Authorization to Release Healthcare Information

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daytime phone #

Release to:

I request/authorize Lacey Fire District 3 to release healthcare information of the patient above to:

For Incident Report:

Please provide as much specific information as possible

Release requiring additional, specific consent:

I understand my signature below authorizes the release of healthcare information relating to my testing, diagnosis, or treatment for:

Minors-

A minor parent's signature is required in order to release the following information: (1) conditions relating to the minor's reproductive care including, but not limited to, contraception, pregnancy, and pregnancy termination, sterilization, and sexually transmitted diseases (ages 14 and older), (2) alcohol and/or drug abuse (ages 13 and older), and (3) mental health conditions (ages 13 and older).
of patient or patient's authorized representative

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(parent, legal guardian, personal representative, etc)