PUBLIC RECORDS REQUEST

King County Fire District #20

District Document Request
To request medical records, please upload a patient-signed Authorization for Release and Disclosure of Medical Information. If the patient is a minor, the Authorization for Release & Disclosure of Medical Information must be signed by a parent or guardian.
First / Last name

First NameLast Name
Today's Date

MonthDayYear
Date
Phone
Format: 000 000 0000 .
Email
example@example.com
Request Type

Other
Date of Incident

MonthDayYear
Date
Date Range

MonthDayYear
Date
Date of Incident
If exact date of incident is unknown, enter date range of occurrence to the best of your knowledge. If exact date is known, use the same date for both the start and end date range.
Address of Incident

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
File / Image upload

Authorization for Release & Disclosure of Medical Information must be signed by a parent or guardian.
Cancelof
District Documents
Please describe what documents you are looking for:
How would you like to receive your documents

Other
Acknowledgment: I hereby certify, under penalty of perjury in the State of Washington, that this request contains no willful misrepresentation and that the information given is true and complete to the best of my knowledge and belief.
Verification
Should be Empty:

King County Fire District #20