Get Prehospital Care Report

FIRE DEPARTMENT CITY OF NEW YORK Public Records Unit / ACR Section 9 MetroTech Center Brooklyn New York 11201-3857 718 999-1998 or 1999 Ambulance Call Report/ Prehospital Care Report Request Form SECTION A CUSTOMER INFORMATION Please print the required information below. Name Telephone Number Address State Zip Code Note Please make sure you complete this form and attach all required documents. Enclose a check or money order made payable to the NYC Fire Department and a stamped self-addressed envelope with postage. Mail checks or money orders directly to the address and unit listed above. Only money orders or checks will be accepted for Requests no exceptions. DO NOT MAIL CASH. PATIENT INFORMATION Please carefully read the instructions below and print the required patient s information* Name of Patient Incident / Date Incident / Time Incident / Location Incident / Borough Hospital taken to AM Is the patient a minor please check only one box PM YES NO Date of Birth / / Last 4 digits of Social Security Number If you have the ACR/PCR please provide ACR/PCR number What is the requester s relationship to the patient please check only one box below Self / Patient Parent / Guardian Executor / Administrator of Estate Other CUSTOMER PLEASE READ AND SUBMIT THE REQUIRED ITEM S BELOW An original notarized letter from the patient authorizing the release of this information* Proof of parental status or guardianship if the patient is a minor. Acceptable proof is a copy of the patient s birth certificate or a court document showing custody / guardianship* Proof that a court has appointed you executor or administrator of the patient s estate if the patient is deceased Letters testamentary or letters of administration. Name Telephone Number Address State Zip Code Note Please make sure you complete this form and attach all required documents. Enclose a check or money order made payable to the NYC Fire Department and a stamped self-addressed envelope with postage. Enclose a check or money order made payable to the NYC Fire Department and a stamped self-addressed envelope with postage. Mail checks or money orders directly to the address and unit listed above. Only money orders or checks will be accepted for Requests no exceptions. Mail checks or money orders directly to the address and unit listed above. Only money orders or checks will be accepted for Requests no exceptions. DO NOT MAIL CASH. PATIENT INFORMATION Please carefully read the instructions below and print the required patient s information* Name of Patient Incident / Date Incident / Time Incident / Location Incident / Borough Hospital taken to AM Is the patient a minor please check only one box PM YES NO Date of Birth / / Last 4 digits of Social Security Number If you have the ACR/PCR please provide ACR/PCR number What is the requester s relationship to the patient please check only one box below Self / Patient Parent / Guardian Executor / Administrator of Estate Other CUSTOMER PLEASE READ AND SUBMIT THE REQUIRED ITEM S BELOW An original notarized letter from the patient authorizing the release of this information* Proof of parental status or guardianship if the patient is a minor..