Merrick Fire Department
Request for Records
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Records being requested
*
What records would you like sent back to you via email (Include as much detail as possible such as full names, dates, descriptions, etc…)
Cost of copies:
Please inform me of the cost of providing paper copies of the following records
Records Inspection
Inform me of the appropriate time during business hours for me to inspect the following records prior to obtaining copies
Records requesting inspection
What records would you like to inspect before receiving copies (Include as much detail as possible such as full names, dates, descriptions, etc…)
Sending of records via E-Mail
For records that can not be emailed to me, please inform me by email of the portions that can be emailed and advise me of the cost for reproducing the remainder of the records requested
Paper copies of records
What records would you like paper copies of (Include as much detail as possible such as full names, dates, descriptions, etc…)
CD-Rom
Please inform me of the cost of having the records supplied to me on a CD-ROM
If my request must be modified, I would prefer to be contacted by phone at this number:
Name
*
First
Last
Email
*
Full Mailing Address
*
Request: I would
Denied Request:
If for any reason any portion of my request is denied, please inform me of the reason in writing and provide the name, address and email of the person or body to whom an appeal should be directed
Reciept of form submission request
If you would like to receive an email receipt of this form submission, please enter a valid email address in the field above.
Submit
If records are Medical Related, below form must be downloaded and submitted by mail or e-mail before records will be released
Merrick FD FOIL HIPAA Release Form
Download