APPLICATION FOR INFORMATION UNDER
TEXAS OPEN RECORDS ACT
Send, Bring or Fax Open Records Request form to:
Texas City Fire Department
1725- 25
th
Street North
Texas City, TX 77590
Phone Number: 409-643-5700
Fax Phone Number: 409-643-5719
CUSTODIAN OF RECORDS FOR TEXAS CITY FIRE DEPARTMENT:
DATE: ________________________________
APPLICANT NAME :_____________________________________________
APPLICANT ADDRESS:___________________________________________
APPLICANT PHONE No.
_____________________________ APPLICANT EMAIL. _____________________________
DATE OF INCIDENT: ______________________________
DOCUMENTS REQUESTED, Include address of incident & type of report: For EMS Patient reports or any HIPPA
protected information, a signed release from the patient or the patient’s legal guardian, must accompany this request.
APPLICANT'S SIGNATURE
I acknowledge that I have viewed or received the documents described above which I requested.
DATE:____I____I____
APPLICANT'S SIGNATURE
(FIRE DEPARTMENT TO COMPLETE SECTION BELOW)
REQUEST APPROVED BY: DATE:
REQUEST DENIED BY: DATE:
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