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Record Request Form EMS

  1. 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.
  2. Print name
  3. Print Agency Name if Applicable
  4. Mailing Address City/State/ZIP
  5. Ambulance Record
    Select one or more of the following that apply to ambulance record search:
  6. Medical Billing
  7. Pre-Hospital
  8. Refusal
  9. EMS
  10. Authorization
    My signature below authorizes the Narragansett Fire Department to disclose copies of ambulance records identified above for :
  11. Print Name
  12. to
  13. Print Location
  14. Date
    For Services Rendered On:
  15. Date and Time
  16. Any Additional Information
  17. 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.
  18. Sign Here
  19. Today's Date
  20. 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.
  21. 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.
  22. Leave This Blank:

  23. This field is not part of the form submission.