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.
| Question | Answer |
|---|---|
| Form Name | Ny Ambulance Call |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | fdny acr form, ambulance call report, new york ambulance report, ambulance call report form |
FIRE DEPARTMENT – CITY OF NEW YORK
Public Records Unit / ACR Section
9 MetroTech Center
Brooklyn, New York
(718)
Ambulance Call Report/
Prehospital Care Report
Request Form
SECTION A |
CUSTOMER INFORMATION |
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Please print the required information below. |
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___________________________________________________ |
__________________________ |
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Name |
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Telephone Number |
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Address |
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___________________________________________________ |
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State |
Zip Code |
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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
SECTION B |
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PATIENT INFORMATION |
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Please carefully read the instructions below and print the required patient’s information. |
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Name of Patient: |
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Incident / Date: |
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____/____/____ |
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Incident / Time: |
______: ______ |
AM |
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PM |
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Incident / Location: |
________________________________________________________________ |
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Incident / Borough: |
________________________________________________________________ |
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Hospital taken to: |
________________________________________________________________ |
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Is the patient a minor (please check only one box)? |
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YES |
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NO |
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Date of Birth: |
_____/ ____/_____ |
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Last 4 digits of Social Security Number: |
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If you have the ACR/PCR, please provide ACR/PCR number: _________________________ |
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What is the requester’s relationship to the patient (please check only one box below)? |
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Self / Patient |
Parent / Guardian |
Executor / Administrator of Estate |
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Other ______________________ |
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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