Fire Report Request Form
This is a request for a copy of a fire or incident report. Please ensure you have the exact date and address in order for the request to be processed without delays. Once completed, click on the Submit button at the bottom. Reports will be e-mailed or faxed within 3 business days of the date submitted. We reserve the right to charge for copies of reports.
Please note that to ensure compliance with the privacy standards of the Health Insurance Portability and Accountability Act of 1996, (HIPAA), 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.
If you have any questions, please call us at 850-891-6600 during our office hours Monday - Friday, 8:00am - 5:00pm.
* Required
Name (First, MI, Last)
*
Your answer
Phone Number
*
XXX-XXX-XXXX
Your answer
How would you like the report sent to you?
If you want the form sent via email, enter your email below. If you would like it by fax, enter your fax number below.
Your answer
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