Request for Fire Report Without Patient Information

Request for Fire Report

(Without Patient Health Information)
This form is for Fire & EMS reports that DO NOT contain Patient Health Information. Fire reports containing PHI may be obtained by completing a “Request for Incident Report with PHI”. This form can be found online or in person at Administrative Headquarters.
Person Requesting Report*
Phone Number*
Email Address*
example@example.com
Date of Incident*

MonthDayYear
Date
Address of Incident*
ex. 1234 Main St, Overland, MO 63114
Business Name of Incident Location (if applicable)
How would you like to receive this report?*

By Postal MailBy EmailPickup In Person
MAIL TO:
Name/Business Name*
Attention of
Address*

Street Address

Apt/Suite

CityState / Province

Postal / Zip Code
EMAIL TO:
Name*
Email*
example@example.com
PICKUP IN PERSON - CALL WHEN READY
Name*
Phone Number*
Please enter a valid phone number.
Signature*

Clear
Date*

MonthDayYear
Date
Print Name*

Payment Details

Fire Report Fee

$25.00

Subtotal

$0.00

Tax

$0.00

Total

$0.00

By signing below I hereby authorize Community Fire Protection District to charge my credit card for the amount shown above. I understand this fee is non-refundable.
Authorization Signature

Clear
Please verify that you are human*
Should be Empty:

Request for Fire Report