RECORDS REQUEST FORM

RECORDS REQUEST FORM

Benton County Fire District #4
Date of Request:*

MonthDayYear
Date
Records Request Type:*

Fire Incident ReportPatient Medical Records (Photo ID or Power of Attorney Required)Other
Record(s) Requested:*
Describe the public records you are requesting. Provide as much details as possible - this will assist staff in searching for records.
This section is to be used ONLY by adult patients (18 years or older), patient guardian or representative requesting a copy of a report for care received from Benton County Fire District #4. If this does not apply, please change the Records Request Type above.
Patient Name

First NameMiddle NameLast Name
Patient Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient Phone Number

Area CodePhone Number
Attach a copy of Driver's License/Photo I.D. or Power of Attorney Document

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Date of Incident:

MonthDayYear
Date
Incident #:
Incident Address/Location:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
REQUESTERS INFORMATION:
Name:*

First NameLast Name
Agency: (If Applicable)
Address: (If requesters address is the same as incident address, indicate by entering "Same" below)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email
example@example.com
Preferred Method of Delivery:*

MailFax (No Charge)PickupEmail (No Charge)
Fees:

$0.00 - Inspection Only

$0.20 - Photocopies, per page

A charge for Media Device (CD/Flashdrive), Postage, Envelope and/or container used may be added.
I DECLARE UNDER PENALTY OF PERJURY THE LAWS OF THE STATE OF WASHINGTON THAT I DO NOT INTEND TO USE ANY LIST OF INDIVIDUALS THAT MAY BE COVERED BY THIS REQUEST FOR COMMERCIAL PURPOSES.
Signature

Clear
Date*

MonthDayYear
Date

Standard Xerographic Copies ________@ $0.20 per page	=$___________
Postage:	=$___________
Other Costs (Media Devices):	=$___________
Total Charge:	=$___________

For Office Use Only:
Records Were:

ReleasedWithheldOther
Date

MonthDayYear
Date
Time

:HourMinutesAM/PM Option
If records withheld, reason for disclosure exemption:
Released By:

First NameLast Name
Attach a copy of documents sent:

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Should be Empty: