Public Records

Patients: To request a copy of your emergency medical report, please provide photo identification and complete the above Authorization Form.

Attorneys and other Agencies: Attorneys representing a patient should provide the following when requesting a medical record:

1. A letter of request on your letterhead that includes the patient's full name, incident date, incident time, and incident location.

2. An authorization to release the record that:

• Is in writing, dated, and signed by the patient
• Identifies Eastside Fire & Rescue as the health care provider
• Identifies to whom the record is to be provided
• States the time period the authorization will be valid, which may not exceed one year.

Attorney Representing a Duly Appointed Personal Representative: Attorneys representing a duly appointed personal representative should provide the following when requesting a medical record:

1. A letter of request on your letterhead including the patient's name, incident date, incident time, and incident location

2. A copy of the document by which the person is the duly appointed personal representative

3. A copy of the Death Certificate

4. An authorization releasing the record that:

• Is in writing, dated, and signed by the personal representative
• Identifies Eastside Fire & Rescue as the health care provider
• Identifies the patient
• Identifies to whom the record is to be provided
• States the time period the authorization is valid, which may not exceed one year.

NOTE: Submissions missing any of the required elements will not be accepted.

 Please allow 5-10 business days for your records to be processed.

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Public Record Request

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Requestor Information

Full Name (required)

Street Address (required)

City (required)

Zip (required)

Phone Number (required)

Email (required)

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Record Request

Description of Requested Records (required)

Patient Name (required)

Patient Date of Birth (required)

Incident Number (If known)

Photo ID

Letter of Request

Proof of Representation

Death Certificate

Your Signature (required)

Confirm e-Signature

Review Electronic Records and Signatures Policy (required)

Read our Electronic Record and Signature Disclosure

I agree to use electronic records and signatures

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Confirm e-Signature

Review Electronic Records and Signatures Policy (required)

Read our Electronic Record and Signature Disclosure

I agree to use electronic records and signatures

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