AUTHORIZATION TO RELEASE PATIENT CARE REPORT

If you were medically treated by personnel of Manchester Fire-Rescue-EMS (MFRE) Department, you, or an agent specified by you, have the right to obtain a copy of the Patient Care Report (PCR) that was generated. A copy of your PCR will be released provided:

[1] You, the subject (patient) of the PCR, appear personally in the Office of the Fire Chief of MFRE, complete an "Authorization to Release Medical Information" and be further prepared to offer current valid photo identification that establishes you are the patient referred to in the PCR, or

[2] You complete an "Authorization to Release Medical Information" and you, or your agent, forward a notarized original form to the Office of the Fire Chief of MFRE, or

[3] You, with Power of Attorney, complete an "Authorization to Release Medical Information" and forward a notarized original form to the Office of the Fire Chief of MFRE along with a copy of the Power of Attorney, or

[4] You, an adult with authority to act for a minor patient, complete an "Authorization to Release Medical Information" and forward a notarized original form to the Office of the Fire Chief of MFRE.

[5] Cash or check, made payable to Manchester Fire-Rescue-EMS, in the amount of $2.50 per report, to be received upon receipt of report.

Upon receipt of a properly completed form, the Privacy Officer of MFRE will provide that a true copy of the requested PCR be produced within thirty (30) days.

HOW TO REQUEST A FIRE/INCIDENT REPORT

BY MAIL:
You must provide the following information (Incident Report Request Form attached)

1. Date of incident/fire
2. Approximate time of day
3. Address of incident/fire (if you do not know the address, you will need to include the cross streets of the incident)
4. Type of fire (e.g. vehicle, house, commercial building, etc.)
5. IF it is a vehicle fire, include the make, model and year of vehicle

Please include with your request:
1. A check or money order for $2.50, payable to Manchester Fire-Rescue-EMS. [Additional fees apply to lengthy reports ($0.50 per page)]
2. A legal size self-addressed stamped envelope
3. All proper information pertaining to the incident

Send your request to:
Manchester Fire-Rescue-EMS
Keeper of the Records
75 Center Street
Manchester, CT 06040

All requests will take up to ten (10) business days to process.

BY TELEPHONE:

You will provide the above information to:

Keeper of the Records
(860) 647-3266
Monday through Friday
8:30 a.m. - 4:30 p.m.
Offices closed 12:00 p.m. - 1:00 p.m.

All requests will take up to ten (10) business days to process. You will be advised when the report is ready so that you may pick it up. Please note that there is a $2.50 fee for each basic report, which must be paid upon receipt. Additional fees apply to lenghty reports ($0.50 per additional page).