Request for EMS or Fire Report

Request for EMS or Fire Report
I hereby submit my request for the following type of report:
Check One:*

EMS Report **If this request is for someone other than yourself, please email a signed HIPAA form to sfd@springfieldohio.govFire Report
Part 1: Requester Information
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Primary Phone Number*

Area CodePhone Number
Secondary Phone Number

Area CodePhone Number
E-mail*
Part II: EMS Report Requests - Patient Information
Patient's Name*

First NameLast Name
Patient's Date of Birth*

MonthDayYear
Date of Incident*

MonthDayYear
Address of Incident*
Relationship to Requester*

SelfSpouseChildOther
If other, please specify*
Note: EMS Reports emailed to the requester are required to be encrypted with a password for privacy protection. You will be required to enter this password in order to open the emailed document.
Note: Written documentation supporting legal right to such protected class information is required in cases where the requester is neither the patient nor the legal guardian for the patient. Such documentation must be provided at the time the request is submitted.
Part III: Fire Report Requests
Date of Fire*

MonthDayYear
Address of Fire*
Should be Empty:

Part 1: Requester Information