Ambulance Call Request Details

The new Ny Ambulance Call Form is now available online. This form is used to request an ambulance for a medical emergency. The form can be filled out by the patient, a family member, or a friend. The form is easy to use and requires only basic information. The form can be submitted online or by fax. For more information, visit our website. Thank you for your time.

Below are some information about ny ambulance call. It is definitely worth finding the time to study this before starting submitting your form.

QuestionAnswer
Form NameNy Ambulance Call
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesfdny acr form, ambulance call report, new york ambulance report, ambulance call report form

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)