Request Healthcare Records Use the online form below to obtain a healthcare information report. Authorization to Release Healthcare Information Please enable JavaScript in your browser to complete this form.Patient Name *FirstLastDate of Birth *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Name at time of incident (if different) *FirstLastPhone *daytime phone #Release to:I request/authorize Lacey Fire District 3 to release healthcare information of the patient above to:Name *FirstLastAffiliation *Phone *Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmail *For Incident Report: Please provide as much specific information as possibleDate & Time of Incident *DateTimeAddress/Location of Incident *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeOther DetailsRelease requiring additional, specific consent:I understand my signature below authorizes the release of healthcare information relating to my testing, diagnosis, or treatment for:HIV/AIDSSexually Transmitted DiseasesReproductive Care (minors only)Mental HealthSubstance AbuseMinors-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 *Clear Signatureof patient or patient's authorized representativeRelationship to patient * Check if patient is a minor ___________________________________________________________________________________________Signature of patient or patient's authorized representativeClear SignatureRelationship/status if signed by anyone other than patient(parent, legal guardian, personal representative, etc) Submit