Patient Care Report Request

Jason Weber, Chief, Fire Department

To help us expedite your records request please either complete our Authorization to Obtain or Release Patient Information form or ensure that your request meets the requirements of the HIPAA Compliant Authorization Form Checklist. There is a $15 fee associated with this records request. Please include a check made payable Marin County Fire Department with your request.

Please mail the signed and completed form, with payment to:

Kellie Sullivan, Custodian of Records
PO Box 518
Woodacre, CA 94973

All requests must meet the following standards to comply with HIPAA regulations.  If you are using your own form rather than the Authorization to Obtain or Release Patient Information form, please ensure that the requirements listed in the HIPAA Compliant Authorization Form Checklist have been met.

HIPAA Compliant Authorization Form Checklist

(42 CFR – Sec. 164.508)

  1. A description of the information that is to be disclosed (The Marin County Fire Department requires the exact date of incident)
  2. The specific name of the person or facility that is to release the information.
  3. The specific name of the person or facility that is to receive the information.
  4. A description of the reason for the request
    • For example: legal action, insurance claim
    • If the patient elects not to provide reason, “at the request of the individual” is a sufficient description.
  5. An expiration date, when the authorization will no longer be valid.
  6. The signature of the patient and date
    • NOTE:  If an authorized representative of the patient is requesting the information, proof of the authority for the representative to act for the patient must also be provided
  7. A statement stating that the patient has the right to revoke the authorization in writing and either:
    • The exceptions to the right to revoke and a description of how the patient may revoke the authorization; or
    • A reference to the Marin County Fire Department’s Notice of Privacy Practices where this right is stated.
  8. A statement indicating the ability or inability to make treatment, payment, enrollment or eligibility for benefits conditional on whether the individual signs the authorization.
  9. A statement indicating the potential for the information being disclosed by the receiver of the information and that the facility disclosing the information can no longer be responsible for the protection of the information.
  10. The authorization must be written in plain language.
  11. A statement that the patient is entitled to a copy of the completed Authorization form.