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Medical Record Request

  1. City of Temple Terrace Fire Department logo

  2. Temple Terrace Fire Department Medical Record Request

  3. Authorization For Use or Disclosure of Health Information

  4. I hereby request and authorize the Temple Terrace Fire Department to release the following records.

  5. Personal Information

  6. For the purpose of*

  7. The foregoing records shall be disclosed to:

  8. The undersigned individual authorizes the release of records:

  9. * I understand that by signing this authorization, I authorize the Temple Terrace Fire Department to disclose the information identified above and related information necessary to accomplish the purpose described.

  10. * I understand that I will be required to provide the TTFD with identification and if I am not the patient or parent thereof, other documentation is reasonably required by the Department to establish my legal authority to execute this authorization.

  11. *I understand that I may revoke this authorization at any time by submitting a written request to the Department , except to the extent that the Department has already taken action in reliance on this authorization. I understand if I do take action to revoke this authorization, it will expire automatically 60 days after the date of signature.

  12. * I understand that the information disclosed under this authorization may be subject to redisclosure by the recipient and no longer protected by federal privacy regulations and other privacy laws.

  13. *I understand that the TTFD charges 15 cents for each one sided copy, 20 cents for two-sided copies, and $1.00 per page for certified copies.

  14. Leave This Blank:

  15. This field is not part of the form submission.