Records Request Form

Date of Request*

Name*

Business/Agency Name

Address*

City/State/Zip Code*

Phone Number*

Would Like Report By:*

Mail
Fax
Will Pick Up
Email

Fax Number

Email Address

Select all that apply

*Windows computer Users hold down the “CTRL” button to make mulitple selections

*Mac computer users hold down “COMMAND” to make multiple selections

*Other

List Records Below

*EMS Reports

EMS reports are medical records and as such are not public records. EMS reports can only be reviewed, inspected or copied by/for the following: patient, legal power of attorney of patient or parent of a minor child if the minor child is the patient. EMS reports may also be reviewed, inspected or copied if the record is subpoenaed or if a valid authorization for release of medical records is signed by the patient and his/her signature is notarized. IDENTIFICATION AND/OR LEGAL DOCUMENTATION IS REQUIRED.

Drop files here or

Accepted file types: jpg, jpeg, png, pdf, Max. file size: 50 MB.

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.

TEL: (623) 974-2321