Authorization for Release of Medical Records

To obtain a copy of your EMS report, please complete the Authorization For Release of Medical Information form. Once you have completed and submitted the Authorization For Release of Medical Information form, our medical/legal custodian of records will contact you to confirm your identity and retrieve any additional supporting documents needed to process the request. Please note reports may be delayed if they are awaiting completion or missing information.

Required fields are marked with an asterisk (*).

Patient Information

* First Name

* Last Name

* Date of Birth

* Email Address

* Phone Number

(xxx) xxx-xxxx

* Street Address

* City

* State

* Zip Code

* I hereby authorize Brevard County Fire Rescue to release my medical records to this Physician or Agency

* Choose how you want your records released

Full patient care report
Patient care report with exceptions

List any exceptions

Patient Care / Incident Report Information

* Incident Date

Incident Number

* Incident Street Address

* Incident City

* Incident State

* Incident Zip Code

All incident report requests are processed within 7 business days upon receipt. It is our policy to fulfill record requests within 10 business days of the incident date. The department may require additional time to process more difficult requests and if so, an estimated time frame will be provided to the requestor.

Type of Request

* Indicate the type of record requested.

I request a copy of my patient care report

Requests for an amendment to your record and requests for restrictions of the use and disclosure of your information should be made by completing a separate form.

Records Delivery

* How would you like your records delivered?

Email
Fax
For pickup by a designated person

Name of designated person

Photo I.D. required for pick up

Patient Authorization Disclosure

I understand that Brevard County Fire Rescue is committed to protecting my personal health information under the Health Insurance Portability Accountability Act (HIPAA) Privacy and Security Rule 45 C.F.R.§§ 164.103, 164.105.

I Understand

I understand that I may select which information may be released by checking the areas provided above. Protected Health Information (PHI) is confidential and protected by federal regulations, which prohibit further disclosure without specific written authorization from me or as otherwise permitted by federal and state law.

I Understand

I hereby understand and agree that requests for electronic copies of my medical records from Brevard County Fire Rescue in electronic form via email may not remain confidential due to the unsecure nature of email transmission. I further understand and agree that Brevard County Fire Rescue, and its employees and/or agents, are not liable in any manner for the disclosure of information transmitted via email request, by virtue of electronic disclosure through an unsecured email system.

I Understand

I understand that this Authorization may be revoked upon written notice to the health care provider except to the extent that action has already been taken in reliance on this Authorization. This Authorization may be revoked by writing or faxing the Office of EMS and specifying the date this Authorization was signed.

I Understand

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