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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.

   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:

    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 :

    My signature below authorizes the Narragansett Fire Department to disclose copies of ambulance records identified above for :

24. Name

    Print Name

25. to
    to

    to

26. Location

    Print Location

28. Date
    For Services Rendered On:

    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.

    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.

    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