FDISP-14 Rev. 2/2014
TOWN OF HUDSON – FIRE DEPARTMENT
15 Library Street · Hudson, New Hampshire 03051 · Tel: 603-886-6021 · Fax: 603-594-1164
Request for Incident Copy
Date: ___________________________________
I am requesting a copy of an incident which occurred on _______________________________,
at the location of _______________________________________________________________,
relative to ____________________________________________________________________.
I understand that I am not entitled to medical information that pertains to other patients without
prior written consent.
Name: _______________________________________
Address: _______________________________________
_______________________________________
Phone: _______________________________________
Signature: _______________________________________
Approved by: _______________________________________
Incident #: _______________________________________
Released by: _______________________________________
Date: _______________________________________
Reports Released:
_______________________________________________________________________________
_______________________________________________________________________________
