Document Request Form

Please fill out entirely

The Santa Rita Fire District conforms to ARS 39-121.03(D)(1) and therefore charges the following fees:

Incident reports if in the current calendar year---------------------------$5.00

Incident reports if archived------------------------------------------------$25.00

USB Drives of reports and or pictures of incidents and or fires----$50.00

Additional copies of USB Drives ----------------------------------------$10.00

Additional postage and or copy charges may apply.

Statute ARS 39-121.03(D)(1) available upon request.

HIPAA COMPLIANT AUTHORIZATION FOR THE RELEASE OF PATIENT

INFORMATION PURSUANT TO 45 CFR 164.508

Name of Healthcare Provider/Physician/Facility/Medicare Contractor: Santa Rita Fire Department

Street Address: 1285 W. Camino Encanto

City, State and Zip Code: Green Valley, AZ 85622

Re:

I authorize and request the disclosure of all protected information for the purpose of review and evaluation. I expressly request that the designated record custodian of all covered entities under HIPAA identified above disclose full and complete protected medical information including the following:

I understand the information to be released or disclosed may include information relating to sexually transmitted diseases, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV), and alcohol and drug abuse. I authorize the release or disclosure of this type of information. This protected health information is requested for disclosure for the following purpose(s):

This authorization is given in compliance with the federal consent requirements for release of alcohol or substance abuse records of 42 CFR 2.31, the restrictions of which have been specifically considered and expressly waived. You are authorized to release the above records to the following representatives in the above-entitled matter who have agreed to pay reasonable charges made by you to supply copies of such records:

I understand the following: See CFR §164.508(c)(2)(i-iii)

a. I have a right to revoke this authorization in writing at any time, except to the extent information has been released in reliance upon this authorization.

b. The information released in response to this authorization may be re-disclosed to other parties.

c. My treatment or payment for my treatment cannot be conditioned on the signing of this authorization.

Any facsimile, copy or photocopy of the authorization shall authorize you to release the records requested herein. This authorization shall be in force and effect until two years from date of execution at which time this authorization expires.