Please utilize this form to request a fire or ambulance report for insurance claims and legal purposes. 

All requests from law firms on behalf of patients for an Ambulance incident must be accompanied by the appropriate Health Insurance Portability and Accountability Act (HIPAA) information.

Click Here to Electronically Pay for the Report via PayPal

HIPAA Release Form

Fire Report $25 / EMS Report $50

Indicates Required Field

Report Type Requested:		Select Below Fire Report EMS Report
First Name:
Last Name:
Address: Street Address Address, City, State, Zip
Phone Number:
Email Address:
Location of Incident:
Date of Incident:
Please Select Your Payment Option:		Select Below I have already paid via the PayPal link above I will be paying via the PayPal link above Please Invoice Me (invoice will be sent to the email address listed above)
Please feel free to add any further comments:
Please Attach HIPPA Release or any other paperwork Here:		Add files...