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.
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.

Records Request Form

TEL: (623) 974-2321