Authorization To Release Patient Care Reports from the City of Albany Department of Fire & Emergency Services

Authorization To Release Patient Care Reports from the City of Albany Department of Fire & Emergency Services
Date of Incident*

MonthDayYear
Date
Address of Incident*

Street Address

Street Address Line 2

CityState

Zip Code
I, First Name* Last Name* , hereby authorize the City of Albany Department of Fire & Emergency Services to release the Patient Care Report with any and all information which may be requested regarding my past and/or present physical condition and any and all treatment modalities rendered in the pre-hospital environment.
I further authorize the City of Albany Department of Fire & Emergency Services to provide an official copy of the aforementioned record to First Name* .
Email*
example@example.com
After completing this form, you will receive a PDF document with your information in the email provided above.

It is then your responsibility to print out the PDF and have the document notarized before mailing to:

Albany Fire Department

26 Broad St

Albany, NY 12202
Should be Empty: