Records request form

Date of Request (required)

Name (required)

Business/Agency Name

Address (required)

City/State/Zip Code (required)

Phone Number (required)

Would Like Report By:

Mail

Fax

Will Pick Up

Provide Fax/Address/Email if selected*

Select all that apply

Other Cont. (explain)

Incident Location

Incident Date

Patient Name

Incident Approx. Time

Select One Indicate whether you are using the public record for Commercial or Non-Commercial purpose. A.R.S. 39-121.03D – Commercial purpose is defined by Arizona Statute as the use of a public for the purpose of: The sale or resale or for the purpose of producing a document containing all or part of the copy, printout, or photograph for sale, or obtaining of names and addresses from such public records for the purpose of solicitation, or for any purpose in which the purchaser can reasonably anticipate the receipt of monetary gain from the direct or indirect use of such public record.

Commercial

Non-Commercial

Select One Indicate whether you intend to review/inspect public records or would like a copy:

Review/Inspect

Copy

Consent Signature

The parties acknowledge and agree that this evaluation may be executed by checkbox consent, which shall be considered as an original signature for all purposes and shall have the same force and effect as an original signature.

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