Fillable Fd240requestforrecords Prr-NonCommercial - Scottsdale.pdf

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Fd240requestforrecords Prr-NonCommercial - Scottsdale.pdf

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LAKE HAVASU CITY FIRE DEPARTMENT
FIRE RECORDS REQUEST
RECORDS REQUEST
REQUESTOR NAME:
BUSINESS NAME:
MAILING ADDRESS: CITY:
STATE:
ZIP:
EMAIL ADDRESS:
PHONE NUMBER:
I am requesting the following:
Emergency Medical Service (EMS) Report (complete back side)
Hazardous Material Incident(s)
Fire Incident Report
Inspection Records for Past Three (3) Years
Fire Investigation Report
Permits
Fire Investigation Photos on CD
Other: (please describe)
Will the record be used in litigation against the United States?
Yes
No
Will the record be used for commercial purposes?
Yes
No
REQUEST DETAILS
Date of
Incident:
Incident #:
Location of
Incident:
Patient’s Name:
(EMS Only)
Lake Havasu City, including its departments, agencies, boards, commissions, officers, officials, agents, volunteers, and employees, does not
warrant and shall not be responsible or liable for any loss, consequence, or damage resulting directly or indirectly from reliance upon the
accuracy, reliability, or timeliness of any record provided pursuant to this request. Any person or entity relying upon record provided pursuant to
this request does so at the person’s or entity’s own risk and assumes the responsibility of verifying any information used or relied upon. Lake
Havasu City is not required to create records to satisfy a request and requestors only have the right to receive records that are already in
existence and in the format in which they are currently kept.
PLEASE INDICATE YOU HAVE READ THE DATE:
DISCLAIMER ABOVE BY CHECKING THIS BOX:
RPR-FD Rev 9/19
Will the record be used in a claim against the United States? YES NO
REPORT PICKED UP Y N
2330 McCulloch Boulevard N. | Lake Havasu City, AZ 86403-5950
Phone (928) 855-1141 | www.lhcaz.gov
DISCLAIMER
Email to: lhcfire@lhcaz.gov
REQUEST NO.:
DATE RECEIVED:
DATE COMPLETED:
For Internal Use Only
PRINT FORM
EMS REQUESTS ONLY
Completion of this document authorizes Lake Havasu City to disclose and release personally identifiable health information as set forth below,
consistent with Arizona Revised Statutes §§ 12-2291, 12-2292, 12-2293, 12-2294 and Federal law concerning the privacy of such information.
I, the undersigned, hereby authorize Lake Havasu City to release to the above, the requested medical reports relating to the pre-hospital care
received.
Signed this
day of
, 20 _____.
Signature of Patient or Patient’s Health Care Decision Maker
Print Name
If signed by the patient’s Health Care Decision Maker, describe your authority to sign on behalf of the individual and
provide documentation supporting described authority:
State of
)
County of
)
Acknowledged before me this
day of
, 20_____.
(notary seal)
NOTARY PUBLIC SIGNATURE
REQUEST COMPLETED BY: DATE:
REQUEST APPROVED BY: DATE:
DELIVERED VIA: MAIL FAX PICK-UP OTHER: __________________________
COMMENTS: No record found based on the information provided. The following record was provided:
RPR-FD Rev 9/19
FOR OFFICE USE ONLY
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Completed 13 July 2020

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