Processing Time: Please Allow Approximately 10 Business Days
Request in person or mail: Request by fax or email: Request records inspection:
Golder Ranch Fire District Golder Ranch Fire District Call 520-825-5943
3885 E. Golder Ranch Drive Custodian of Records to speak to the Records
Attn: Custodian of Records (520) 825-5984 Fax Specialist to schedule a time
Tucson, AZ 85739 to inspect records. A.R.S. 39-121
Requestor Information: Is this records request for a commercial purpose: Yes No (check one)
A.R.S. 39-121.03 D. For the purpose of this section, commercial purposemeans the use of a public record for the purpose of sale or resale for the
purpose of producing a document containing all or part of the copy, printout or photograph for sale or the obtaining of names and addresses from public
records for the purpose of solicitation or the sale of names and addresses to another for the purpose of solicitation or for any purpose in which the
purchaser can reasonably anticipate the receipt of monetary gain from the direct or indirect use of the public record. Commercial purpose does not mean
the use of a public record as evidence or as research for evident in an action in any judicial or quasi-judicial body.
Date of Request: __________ Reason for Request: ________________________________________
Requestor Name (Please print legibly) : __________________________________________________
Requestor Address: __________________________________________________________________
City: ___________ State: _______ Zip Code: ______ Email: ________________________________
Requestor Signature: _____________________________ Phone No: _________________________
Special Note for Medical Record Request (ANY un-redacted record that contains a patients protected health
information): Patients requesting medical records must provide proof of identification (government issued photo I.D.). Third
parties requesting a patients medical record must attach one of the following to this Records Request Form: (1) a notarized
HIPAA– compliant release, per 45 C.F.R. §164.508 signed by the patient; or (2) a court order signed by a judge authorizing
release (45 C.F.R. §164.512). A subpoena without a HIPAA-compliant release or court order is not sufficient. For questions
call (520) 825-5943 or email:
Environmental Report/Fire Code Violation Inquiry:
Property Address: ___________________________________________________________________
Information Requested: _______________________________________________________________
Fire Report: Due to their size, fire reports cannot be emailed.
Date of Incident: ________________________ Time of Incident: ______________________________
Incident Address: ____________________________________________________________________
Medical Report:
Information Requested: Medical Report Bill Both
Patients Name: ____________________________________ Date of Incident: ___________________
Incident Address: ____________________________________________________________________
City/Town: ______________________________________ Zip Code: __________________________
Document Type Requested: Paper Copy Emailed Copy CD
(.25 cents/page) Fees May Apply $10.00 plus .25 per page for electronic copies
Please notify me to pick up this record in person I am requesting this information be sent by mail
(.25 cents per page or cost of cd plus postage)
Revised 3/2020
Information Requested: _______________________________________________________________
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