Fire Report Request Form

Name Name First Last
Email
Phone Phone - ### - ### ####
Incident Date Incident Date / MM / DD YYYY
Incident Time Incident Time : HH MM AM/PM

If not known, leave blank
Incident Type

Incident Type Fire - Residential Fire - Commercial Fire - Vehicle Fire - Property Medical Service Vehicle Rescue Other Other
Incident Address Incident Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Please include street # and street name, i.e. 123 Oak Lane. If incident did not happen at a specific address, include name of street or crossroads of intersection.
Your Interest In Incident

Your Interest In Incident Owner Occupant Insurance Company Other Other
Insurance Company Name
Questions or Comments
HIPAA NOTICE

Please note that to ensure compliance with the privacy standards of the Health Insurance Portability and Accountability Act of 1996, (HIPAA), medical records cannot be delivered by electronic mail transmission (e-mail). Patient information will not be disclosed to anyone without appropriate authorization. Appropriate authorization includes: written request directly from the patient and proof of identity, authorization, subpoena, or court order. For more information on obtaining medical incident reports, please call (817) 295-9539.

WE RESERVE THE RIGHT TO CHARGE FOR COPIES OF REPORTS.
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Fire Report Request Form

HIPAA NOTICE