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:*
Please describe the public records you are requesting. Be as specific as possible to help staff locate the records more efficiently. For example, you might write: "I am requesting a copy of the ambulance bill from my transport to the hospital last week," or "I am requesting a copy of the fire report from the incident when my chicken coop burned down." You can also include details such as dates, locations, or names involved, if known.
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 of Requester:*

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: