Information Request Form « Pflugerville Fire Department ESD 2

Instructions:

Provide the information requested in the boxes below. This information is required to verify the District's response to an incident. This request must be presented along with the fee of $2.00 to process the report. No cash is accepted, the fee must be paid by check, credit card, or money order.

Requested Information

This request is for a copy of the run summary report prepared after the fire department responds to an incident.

Type of Incident*

Fire

Medical

Public Record

Other

Please Specify Type of Record*

Date or Start of Range*

Please supply either the exact date, or the start of a range.

End of Range

Date of Incident*

Time of Incident

Are you Requesting for Yourself or Others

Requesting for Myself

Requesting on Behalf of Another

Requesting medical information on behalf of another requires a completed copy of ADM-018c, "Authorization for Release of PHI"

ADM-018c: Authorization for Release of PHI*

Max. file size: 2 MB.

Owner / Occupant / Patient Name:*

Person(s) Involved

Address or Location of Incident:*

All requests for PHI must be made in writing by the patient or the patient's designee (requires power of attorney). The requestor must provide one form of identity before any information will be released.

Public Record Specifics*

If your request is for a public record, you must be singular and specific in your request for information.

Requester's Information

Name of Person Making Request*

First Last

Email*

Requester's Mailing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Cell Phone

Requester's Identification*

Max. file size: 2 MB.

A copy of the requestor’s government issued photo ID MUST be submitted with ALL public information requests.

Moderate

ON

Information Request Form

Public Information Request Form

Instructions:

Requested Information

Requester's Information