AUTHORIZATION FOR RELEASE OF INFORMATION
I hereby request and authorize the Kannapolis Fire Department to release the
records specified below:
General Fire Incident Report
Limited records (specify)
Information:
Patient/Business Name
Date of Birth
Date of Service
Incident Location
Information for the insurance
Company information for attorney
Personal use (specify)
Other (specify)
Name of person or agency information is being disclosed to
Address
City State Zip
Phone/Fax Number
Date signed Signature of authorized representative*
Parent
Authorized representative
Surviving spouse
Legal guardian
Administrator/Executor of Estate*
Other (specify)
*
If legal guardian, adm
inistrator or
executor
of
est
ate,
legal
proof
of
this
status
m
ust accompany this authorization. The parent or authorized
representative may revoke this authorization at any time by submitting a written request to the department. This authorization will expire after each
use.
NOTE TO THE RECIPIENT OF THE ATTACHED RECORDS PROHIBITION OF REDISCLOSURE
This information has been disclosed to you from records whose confidentiality is protected by state law. State law prohibits you from making any further disclosure of such
information without the consent of the person to whom such inform
ation pertains, or as otherwise permitted by state law, with regard to HIV/AIDS records; a specific, written
consent is required. A general authorization for the release of medical or other information is NOT sufficient for this purpose.
A COPY OF THIS DOCUMENT ACCOMPANIES THE RECORDS DISCLOSED
Kannapolis Fire
401 Laureate Way
Kannapolis, NC 28081
FAX
704
-920
-4262
Incident Number
For the purpose of:
Please email to: KannapolisFire@kannapolisnc.gov
Please fax to: 704-920-4262
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