EMS FIRE APPLICATION

FIRE/EMS Report

Choose Report Type

EMS

Fire

Your Contact Information

First Name:*

Last Name:*

Mailing Address:*

City:

State:

Zip Code:

Organization:

Phone Number:*

(Example 999-999-9999)

Email Address:*

Emergency Medical Services Report

Patient Name:

Patient Date of Birth:

Last Four Digits Of The Patients Social Security Number:

Patient Home Address:

Incident Number:

(Example PF/PP 21092700000123)

Incident Date Range

Start Date:

End Date:

Incident Time:

Incident Location:

Supportive Documents

You can add your digital letter of request here along with any supportive documentation. Supportive documentation can include:

A copy of your driver’s license if requesting your own documents.
Official letter of request from your office or law firm.
A signed HIPAA compliant release of records if requesting other parties’ records.
A power of attorney if the person is living but cannot request for themselves.
A Letter of administration or executor documentation if the party is deceased.

Upload your files: