EMS Fire Records Request Form

HCESD48 utilizes ChartSwap under the name Harris County EMS District 48.

Online Request Form for EMS & Fire Incident Report

"*" indicates required fields

I am requesting the Harris County Emergency Services District No. 48 record types selected below:*

FIRE REPORT. Report created by the Incident Commander that complies with the rules of the National Fire Incident Reporting System (NFIRS).

EMS/MEDICAL REPORT. A patient authorization form is required if report contains confidential medical information and is requested by any party other than the patient or a court ordered subpoena of records. Court Orders do not require additional information, however, patient's MUST provide photo identification before the report can be released. A copy of their photo ID shall be attached to the completed Fire/EMS Incident Request Form.

The information requested below must be completed in full. If you do not have the necessary incident information, you may contact the Harris County Emergency Services District No. 48 Administration Office at (281) 599-8888 for assistance.

Please note: All incident report requests are processed within seven (7) business days upon receipt. It is our policy to fulfill record requests within ten (10) business days of the incident date. The Department may require additional time to process requests that are more difficult and if so, an estimated period will be provided to the requestor.

Requester First Name*

First

Requester Last Name*

Last

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

ex: (888) 888-8888 or 888-888-8888

Email*

Incident Date*

Incident Time*

Type of Incident*

Comments

Requestor Driver's License*

Accepted file types: pdf, jpg, png, Max. file size: 50 MB.

All EMS & Fire incident requests must include a copy of the requestor's driver's license, front side only. *Accepted file types: pdf, jpg, png

HIPAA Authorization - Medical Report Requests

Drop files here or

Accepted file types: pdf, doc, docx, Max. file size: 50 MB, Max. files: 3.

Medical report requests must include a valid HIPAA Authorization and supporting documentation by the patient (if applicable). *Accepted file types: pdf, doc, docx