City of Temple Terrace Customer Service

2. 
3. Temple Terrace Fire Department Medical Record Request
5. Authorization For Use or Disclosure of Health Information
7. I hereby request and authorize the Temple Terrace Fire Department to release the following records.
9. Personal Information

   1. All Medical Records
   2. Limited Records (specify)
11. Specify
13. First Name*
14. Last Name*
16. Date of Birth*
17. Date of Service*
18. Upload ID*
20. Incident # (office use only)
21. Incident Location*
23. For the purpose of*

    1. Continuing to receive medical care
    2. Information for attorney
    3. Information for the insurance company
    4. Personal use of the patient
    5. Other
25. The foregoing records shall be disclosed to:
27. First Name*
28. Last Name*
30. Address1*
32. Address2
34. City*
35. State*
36. Zip*
38. Email*
40. Telephone Number*
42. The undersigned individual authorizes the release of records:

    1. Patient
    2. Parent
    3. Legal Guardian
    4. Authorized Representative
    5. Spouse
    6. Administrator/Executor of Estate
    7. Other (specify)
44. Specify
46. E-Signature of Patient or Authorized Representative *
47. Date Signed*
49. Print Name of Patient or Authorized Representative*
51. * I understand that by signing this authorization, I authorize the Temple Terrace Fire Department to disclose the information identified above and related information necessary to accomplish the purpose described.
53. * I understand that I will be required to provide the TTFD with identification and if I am not the patient or parent thereof, other documentation is reasonably required by the Department to establish my legal authority to execute this authorization.
55. *I understand that I may revoke this authorization at any time by submitting a written request to the Department , except to the extent that the Department has already taken action in reliance on this authorization. I understand if I do take action to revoke this authorization, it will expire automatically 60 days after the date of signature.
57. * I understand that the information disclosed under this authorization may be subject to redisclosure by the recipient and no longer protected by federal privacy regulations and other privacy laws.
59. *I understand TTFD charges $1 per page for any records 15 pages or more.
Leave This Blank:


61. 1. Receive an email copy of this form.
62. Email address

    This field is not part of the form submission.

63. Submit Submit and Print

* indicates a required field