EMS Report Request

  Refugee-Canyon Joint Fire District

111 Basin St, Hebron, OH  43025 | Phone: (740) 928-4721|

Fax: (740) 928-2726 | Email: ems@rcfiredistrict.org

EMS REPORTS

Patient care reports are protected by the federal Health Information Portability & Accountability Act (HIPAA) and, therefore, are not public documents that can be requested by anyone.  For more information on obtaining a copy of an EMS report and to make a request, fill out the form below.

Note: In order to request a copy of an EMS report, the requesting party must meet one of the following requirements outlined below.  We ask that you do not fax your request to the department unless you have coordinated your request with the department.  Requests submitted via blind fax may be delayed.

  • Patient – If you were the patient and are requesting a copy of the report for the care that was provided to you, you can obtain a copy of the report in one of the ways:  1) Schedule a time/date with the EMS Division when you can visit the firehouse in person to retrieve a copy of the report.  Upon your arrival, you will be required to present a valid photo ID proving your identity prior to the release of the report.  2) Download and complete the “Release of Medical Information” form in the documents section below.  Mail the completed form; a self-addressed stamped envelope; and a letter with your name, date of the incident, and location of the incident to the station address at the bottom of the page.
  • Patient’s Legal Guardian or Medical Power-of-Attorney – Follow the steps outlined above for what is required of a patient’s request.  In addition, the requestor must provide proof of their relationship to the patient in the form of a birth certificate, POA document, or other legal documentation.
  • Attorney or Law Office – EMS reports may be made to an attorney’s office as long as the request is accompanied by a “Release of Medical Information” form signed by the patient or other legal representative.  A release form originating from the law office is acceptable and does not have to be the actual form provided below.
  • Subpoena of Information – EMS reports may be provided to legal authorities with a valid subpoena.  A copy of the subpoena must be provided with the request.

Form: Authorization to Use and Disclose Protected Health Information

Request EMS Report

Requestor Information

Patient Information

Time of Incident (approx.)
:
File Upload
Maximum upload size: 5MB

Request Other Reports

EMS Report

Fire Report

Inspection Report