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*
Email*
example@example.com
Request Type*

Fire Incident ReportMedical Incident ReportDistrict DocumentOther
Date of Incident

MonthDayYear
Date
Address

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*

EmailUSPSOther
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.*

YESNO
Verification*
Should be Empty:

King County Fire District #20