Request Healthcare Records – Lacey Fire District 3

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

Authorization to Release Healthcare Information

Patient Name *

First

Last

Date of Birth *//

Name at time of incident (if different) *

First

Last

Phone *

daytime phone #

Release to:

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

Name *

First

Last

Affiliation *

Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

For Incident Report:

Please provide as much specific information as possible

Date & Time of Incident *

Date

Time

Address/Location of Incident *

Address Line 1

Address Line 2

City

State

Zip Code

Other Details

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).

Signature *

of patient or patient's authorized representative

Relationship to patient *

Check if patient is a minor

___________________________________________________________________________________________

Signature of patient or patient's authorized representative

Relationship/status if signed by anyone other than patient

(parent, legal guardian, personal representative, etc)