Chandler Fire Medical Records Request

Requesting a medical record for yourself; you must provide a valid picture ID.
Requesting a medical record on behalf of another person; you must submit a request, provide the patient's notarized signature, provide a subpoena for the records, or provide proof of a Medical Power of Attorney. Requesting a medical record for a deceased relative; you must provide a copy of the patient's death certificate along with your valid picture ID and relationship to the deceased.
Requesting a medical record for a minor; a parent or guardian must provide a copy of the patient's birth certificate along with your valid picture ID.
Insurance companies or law offices requesting a medical record must provide a Medical Records Release Form signed and notarized by the patient, legal guardian, person with Medical Power of Attorney, or subpoena.
The report(s) will be faxed or made available for pick-up as soon as processing is complete. Requests submitted with all required documentation will usually be processed within 10 business days of receipt.
It is the policy of the Fire Department to comply with all City, State of Arizona and Federal laws and regulations regarding the release of public records. Please be aware that the City may deny inspection of certain records if they are made confidential by State or Federal law.

Report Information

Important: Provide as much information as possible to locate the medical record.

Incident Number

Incident Date

Incident Location

Patient's Name

Date of Birth

Requestor's Information

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Phone Number

Fax Number

Email

How would you like the medical record delivered to you?

Call or email me when the medical record is ready for pick-up

Fax the medical record to the above number - for subpoena requests only

Completed by

Date Completed

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