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Record Request Form EMS

2. EMS Records Request
   All lawfully applicable fees shall apply to any request for records from the Narragansett Fire Department. Please review the following Rhode Island General Law for fees associated with open records requests.
4. State Law
   Link to State Law
6. Name
   Print name
7. Agency Name
   Print Agency Name if Applicable
9. Mailing Address
   Mailing Address City/State/ZIP
11. Daytime Phone
12. Fax/Cell
13. Email Address
15. Ambulance Record
    Select one or more of the following that apply to ambulance record search:
17. Medical Billing

    1. All related medical and billing information
18. Pre-Hospital

    1. Pre-Hospital Care Report
19. Refusal

    1. Refusal of Medical Care Report
20. EMS

    1. No Medical Need/Public Assist Report
22. Authorization
    My signature below authorizes the Narragansett Fire Department to disclose copies of ambulance records identified above for :
24. Name
    Print Name
25. to
    to
26. Location
    Print Location
28. Date
    For Services Rendered On:
29. Date
    Date

    Date
    Date and Time
31. Additional Information
    Any Additional Information
33. Note:
    This authorization may be revoked at any time. Unless revoked earlier, this consent expires after 180 days from date of signing. To revoke this authorization send a written request to Narragansett Fire Department, 40 Caswell St. ,Narragansett, RI 02882.
35. Signature
    Sign Here
36. Date
    Date

    Date
    Today's Date
38. Attachments
    Please utilize the attachment link above to submit any required release forms relating to this request. Ensure that all forms are completely filled out prior to submission, contain the necessary signatures, and outline the parameters of the permission given.
40. Disclaimer
    All records subject to HIPAA regulations and Fire Investigations that contain personal or private information will need to be picked up in person and the individual requesting the form must be present with the proper identification. We will contact you when the form is prepared and available for pick up.
Leave This Blank:


42. 1. Receive an email copy of this form.
43. Email address

    This field is not part of the form submission.

44. Submit

* indicates a required field