Scroll To Top
Snohomish Regional Fire & Rescue

Public Records Request - Medical Records

Note: Any form field marked with ✽ is a required field and must have information selected or entered.

Requestor Contact Information
Description of Public Records Requested

Please provide a detailed description of the requested information ✽

characters remaining >>
Request Format

Select the desired format you would like to receive the information in.

Attachment(s)

Please provide a copy of a current photo identication document.

Please attach a signed an effective patient consent to release of medical records form (might want to have a link to a consent form). If you do not have patient consent, please identify the authority you are relying on to obtain the medical records.

 

In addition to the required "Photo Identification" attachment, you may include up to thrtee(3) attachments with this request.   —   Allowed Format(s) : .pdf / .jpg / ,jpeg / .gif / .png

Signature
 ✽
I agree that this form may be electronically signed, and that my electronic signature has the the same validity, enforceability, and admissibility as my handwritten signature.
Top
Close

Fee Schedule

[ Download Fee Schedule ]

Pursuant to RCW 42.56.120, the District is not calculating all actual costs for copying records because to do so would be unduly burdensome for the following reasons: (1) the District does not have the resources to conduct a study to determine all of its actual copy costs; (2) conducting such a study would interfere with the essential functions of the District and (3) this policy adopts the fee schedules and requirements as provided by the state legislature in RCW 42.56.120. The following charges shall be imposed to reimburse the District for costs incurred in providing public records and may be adjusted by staff if the statutory fees change.

General Records. With the exception of medical incident reports, the District shall charge a fee of fifteen cents per page for providing a photocopy or a printout of an electronic records. The District may also charge for the actual cost of any container or envelope used to deliver records and the actual cost of postage or delivery charges.

Electronic Records. With the exception of medical incident reports, if records are provided in electronic format the District shall charge a fee of ten cents per page for hard copies scanned into an electronic format and five cents for each four electronic files or attachments transmitted electronically and ten cents per gigabyte for transmitting electronic records. The District may also charge for the cost of media on which the record is disclosed (CD, DVD, etc.). The Records Retention Officer may waive copying fees as a matter of administrative convenience for small requests.

Medical Incident Reports. In accordance with chapter 70.02 RCW the District may charge the rates established by the Department of Health (WAC 246-08-400), which currently establishes a clerical fee for searching and handling requests for medical incident reports of $28.00 for each report. In addition, the District shall charge $1.24 per page for the first 30 pages and $.94 per page for all additional pages of each report copied or printed out. The Records Retention Officer may waive copying fees or use the general record fees as a matter of administrative convenience for small requests.

Video and Audio Tapes. The District shall charge the actual cost it incurs in commercially duplicating audio or visual tape records.

Customized Service Charge. The District may impose a customized service charge for requests that require the use of IT expertise beyond the level that can be met by staff. In the event District Records Retention Officer determines that IT expertise will be necessary to comply with the request, the District Retention Officer shall use the following procedures: