EMS Patient Care Report Request

Attorneys representing a patient should provide the following when requesting a medical record:

1. A letter of request on your letterhead that includes the patient’s name, incident date, incident time and incident location
2. An authorization to release the record that:

• •  Is in writing, dated and signed by the patient
  •  Identifies the Singerly Fire Company as the health care provider
  •  Identifies to whom the record is to be provided
  •  States the time period for which the authorization will be valid, which may not exceed one year

Note: Authorizations missing any of the required elements will not be accepted.

Send all of the required documentation with a check or money order to “Singerly Fire Company” to:

Singerly Fire Company
Attention: Assistant Chief for EMS
PO Box 444
Elkton, MD  21922-0444