E-Gov Services City Of Monroe

Document Request, EMS Incident Report - FOIA

WARNING! Please do not use this form to report issues of an emergency nature or for conditions requiring an immediate response. If your issue is an emergency, please use the telephone and dial 911 or call 734-243-7070.

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Use this form to request an EMS incident report for insurance or other reasons, for an event responded to by the City of Monroe Fire Department.

* Information is required.

Contact Information

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

Incident Location:

* Address:	- Or Other Not Listed -
Unit:

	Please provide the name of the person listed on the incident report.

* List the approximate start date of the incident as mm/dd/yyyy.

* List the approximate end date of the incident as mm/dd/yyyy.

* Please list the best time and method to contact you regarding the availability of your report.

What is your preferred method to receive the requested information?

Notification of HIPAA Privacy protection:

- Must be patient, guardian, or executor of estate; must provide proof to release any protected information.
- Signature and documentation will be required after you have been notified that the requested information is available for pickup.

Legal requests from subpoenas:

- Mailed to City of Monroe Fire Department, 75 Scott St., Monroe, MI 48161
- Include the written release for disclosure of patient protected information.

The City of Monroe may charge a reasonable fee for research, duplication, and redaction. The average cost of an incident report is $5 and includes all standard forms. Additional charges may incur for excessively large reports and/or pictures and, if necessary, a deposit may be required.

The Michigan Freedom of Information Act allows five business days to respond to a request with an additional ten business days permitted as an extension.

Please include any comments or questions if applicable.

Check here to have email confirmation of this request sent.

* Information is required.

Notes:

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

Information we receive may be considered public information which is subject to disclosure under current state law. Learn more about our Privacy Policy.

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