Ny Ambulance Call PDF Details

In the bustling metropolis of New York City, the Fire Department's Public Records Unit / ACR Section provides an essential service through the Ambulance Call Report/Prehospital Care Report Request Form. Located at 9 MetroTech Center in Brooklyn, this form is a critical tool for individuals seeking to obtain records of ambulance services provided by the city. It meticulously outlines the process for requesting these reports, emphasizing the need for accurate customer and patient information, including names, addresses, and detailed descriptions of the incident. Importantly, the form underscores the necessity of accompanying the request with a check or money order payable to the NYC Fire Department, alongside a self-addressed envelope for the response. Moreover, it stresses the importance of not sending cash and provides clear guidelines on submitting proof of relationship to the patient, whether it be through notarized letters, proof of guardianship for minors, or court documents for estate executors. With a nominal fee of $1.50 per report, this document symbolizes a blend of bureaucratic procedure and the vital need for access to one's medical records, encapsulating the city's commitment to transparency and individual rights in prehospital care scenarios.

QuestionAnswer
Form NameNy Ambulance Call
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesambulance request form, fillable ambulance call report request form, ambulance call report, fdny ambulance call report

Form Preview Example

FIRE DEPARTMENT – CITY OF NEW YORK

Public Records Unit / ACR Section

9 MetroTech Center

Brooklyn, New York 11201-3857

(718) 999-1998 or 1999

Ambulance Call Report/

Prehospital Care Report

Request Form

SECTION A

CUSTOMER INFORMATION

 

 

Please print the required information below.

 

___________________________________________________

__________________________

Name

 

Telephone Number

___________________________________________________

 

Address

 

 

___________________________________________________

 

State

Zip Code

 

Note: Please make sure you complete this form and attach all required documents. Enclose a check or money order made payable to the NYC Fire Department and a stamped self-addressed envelope (with postage). Mail checks or money orders directly to the address and unit listed above. Only money orders or checks will be accepted for Requests (no exceptions). DO NOT MAIL CASH.

SECTION B

 

PATIENT INFORMATION

 

 

 

 

 

 

 

 

 

Please carefully read the instructions below and print the required patient’s information.

Name of Patient:

________________________________________________________________

Incident / Date:

 

____/____/____

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Incident / Time:

______: ______

AM

 

 

PM

 

 

 

 

 

 

Incident / Location:

________________________________________________________________

Incident / Borough:

________________________________________________________________

Hospital taken to:

________________________________________________________________

 

 

 

 

 

 

 

 

Is the patient a minor (please check only one box)?

 

 

YES

 

NO

 

 

Date of Birth:

_____/ ____/_____

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last 4 digits of Social Security Number:

________________________

 

 

If you have the ACR/PCR, please provide ACR/PCR number: _________________________

What is the requester’s relationship to the patient (please check only one box below)?

Self / Patient

Parent / Guardian

Executor / Administrator of Estate

 

Other ______________________

CUSTOMER – PLEASE READ AND SUBMIT THE REQUIRED ITEM(S) BELOW

•An original notarized letter from the patient authorizing the release of this information.

•Proof of parental status or guardianship, if the patient is a minor. Acceptable proof is a copy of the patient’s birth certificate or a court document showing custody / guardianship.

•Proof that a court has appointed you executor or administrator of the patient’s estate, if the patient is deceased (Letters testamentary or letters of administration).

•Payment in the form of a check or money order in the amount of $1.50 for each report.

PR1 (July-08)

How to Edit Ny Ambulance Call Online for Free

Submitting files along with our PDF editor is easier as compared to nearly anything. To enhance fdny ambulance call report the form, there is nothing for you to do - basically keep to the steps listed below:

Step 1: Step one would be to click the orange "Get Form Now" button.

Step 2: The form editing page is currently open. It's possible to add text or edit existing content.

Provide the required details in every single part to get the PDF fdny ambulance call report

ambulance request blanks to complete

Provide the requested data in the Is the patient a minor please, YES NO, Date of Birth, Last digits of Social Security, If you have the ACRPCR please, What is the requesters, Self Patient, Parent Guardian Executor, CUSTOMER PLEASE READ AND SUBMIT, Proof of parental status or, certificate or a court document, Proof that a court has appointed, Letters testamentary or letters of, Payment in the form of a check or, and PR July box.

ambulance request Is the patient a minor please, YES NO, Date of Birth, Last digits of Social Security, If you have the ACRPCR please, What is the requesters, Self Patient, Parent Guardian Executor, CUSTOMER PLEASE READ AND SUBMIT, Proof of parental status or, certificate or a court document, Proof that a court has appointed, Letters testamentary or letters of, Payment in the form of a check or, and PR July blanks to fill

Step 3: Press the Done button to save the document. Then it is available for upload to your gadget.

Step 4: Generate copies of the form - it can help you stay away from possible concerns. And don't be concerned - we are not meant to distribute or read the information you have.

Watch Ny Ambulance Call Video Instruction

Ny Ambulance Call isn’t the one you’re looking for?

Related Documents

  • Ny Form Attorney

    "... New York state bar association power-of-agent 18 10 eff 12/10 2010 laws ch. 340 Page of power of agent new york statutory brief form. You can ask your agent any questions. If you want to ..."

  • California Attorney Complaint

    "... The state bar of California office of chief trial counsel in take 1149 South Hill Street Los Angeles california Phone 213-765 1000 Fax 213-765 1168 http://calbarca.gov Dear complaining witness, Please complete this california lawyer complaint ..."

  • Certificate Of Amendment Ny Sample

    "... Page of dos 1554 Rev 06 12 New York State Department of State Division of Corporations one Commerce Plaza 99 Washington Avenue Albany NY 12231 www DosstateNYU Certificate of Amendment of The Certificate of Incorporation ..."

  • Ny Adoption Form

    "... In the case of an adoption, petition form 27 for the access to sealed records 2006. Surrogate Court of New York County. The petitioner respectfully claims that the adopted child was not named in this ..."

Please rate Ny Ambulance Call

1 Votes

Related Resources

If you believe this page is infringing on your copyright, please familiarize yourself with and follow our DMCA notice and takedown process - click here to proceed .