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Get Records Request Form For Fire Districts

, State, Zip: Phone Number: DOCUMENT DETAILS Is this records request for a commercial purpose? Yes or No If yes, describe: Please indicate: Fire Report Medical Report Vehicle Fire other: Date/Time of Incident: Address of Incident: Name of Patient: Note: According to the Health Insurance Portability Accountability Act (HIPAA), Northwest Fire District is not permitted to disclose and/or release medical information without a signe.

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