E-Gov Services Buckeye

Release of Medical Records Authorization Form

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It is not necessary to register to submit a Service Request. However if you do register then you will be able to track all the Service Requests submitted under your registration ID.

Submitting an email address with your Service Request will result in confirmation that the Request has been received and will allow you to receive status updates for your request.

Purpose. This form is used to request medical records from the Buckeye Fire Department.

PLEASE NOTE: We do not provide ambulance billing information. Please contact the ambulance service provider directly if this information is needed (On most occasions we utilize the Buckeye Valley Fire District at 623-386-5906).

If relative is requesting release of medical records - Must have one of the following: 1) Notarized Signature of Patient on this Authorized Release Form, or 2) Death Certificate of Patient.

If Patient is requesting release of medical records - Must have one of the following: 1) Valid Driver's License, 2) Birth Certificate - original or certified copy, 3) Valid State ID card.

If insurance company or law office release of medical records - Must have ONE of the following: 1) Authorized Release Form with patient's notarized signature, 2) Subpoena or other valid court order. NOTE: If patient is a minor, the Authorized Medical Release form may be signed by a legal guardian.

If law enforcement entity is requesting release of medical records - Must have one of the following: 1) Authorized Release Form with the patient's notarized signature, 2) Subpoena or other valid court order.

If you have any questions regarding what is required for your request please contact Randy Perkins at 623-349-6726.

* Information is required.

Contact Information

First Name:
Last Name:
Business Name:
Email:
Daytime Phone:	() –
Fax:	() –
Address:
City:
State:
ZIP:

Patient name (Last, First, MI)

Patient date of birth

Patient sex

Patient social security number

* Date of incident

Time of incident

* Incident location

Please add any addition information here

* Is this a request from a law firm?

Check here to have email confirmation of this request sent.

* Information is required.

If your circumstance requires a notary signature, please fill out this request form, submit it, then print it out to have notarized. All notarized Medical Records forms with notarized signatures can be brought to the Town of Buckeye Fire Department, 530 East Monroe, Buckeye, Arizona 85326.

All medical records released are subject to a $5.00 fee up to 10 pages, where each page after the initial charge is $.50.

If you would like your request to be mailed or faxed you may send a check made payable to 'Town of Buckeye' and sent to the above address ATTN: Erika Van Valkenburg.

Notes:

If you send us a message, you'll receive a Tracking Number allowing you to follow-up with your request, at your convenience.

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