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Park Forest Fire Department Request for Records

2. 

4. First Name

5. Last Name

7. Company (if applicable)

9. Address1

11. Address2

13. City

14. State

15. Zip

17. Phone #

19. Information Requested (i.e. fire report, fire prevention records, etc.)

    Note - A “Patient Request for Access” form should be completed for EMS record requests. EMS records are protected under HIPAA and will only be given to the patient or patient’s guardian if the patient is a minor. Valid picture ID is required to obtain medical records.

21. Date / Time / Location of Incident

23. Incident Number(s) (if known)

25. A response to most requests will be made within five business days.

29. Date Received

30. Received By

32. Request Filled On

33. Filled By

35. Notes

Leave This Blank:


37. 1. Receive an email copy of this form.
38. Email address

    This field is not part of the form submission.

39. Submit

* indicates a required field