Emergency Medical Services Incident Patient Reports
&
Fire Incident Reports Requests

   Requests For:

• Information from Emergency Medical Services Incident Patient Reports
  
  
• Information from Fire Incident Reports

To receive information from Emergency Medical Services Incident Patient Reports, you must mail your request to:

Montgomery County Fire and Rescue Service
Office of Quality Assurance
100 Edison Park Drive
2nd Floor
Gaithersburg, MD 20878

Questions: 240-777-2418

Please provide:

1. a stamped, self-addressed business size envelope;
   
2. the date the patient was transported;
   
3. the approximate time the patient was transported;
   
4. the patient's full name;
   
5. the incident location, or the address from which the patient was transported;
   
6. the type of incident and/or injury, e.g., vehicle collision, heart attack, etc.; and
   
7. the patient’s signature on a document requesting that his/her patient information be released, indicating the person(s) legally authorized to receive this information.
   
8. If the individual making the request is not the patient, the relationship to the patient must be indicated. If the patient is unable to complete a request, the patient’s legally authorized representative must provide a signed consent for the release of information, with documentation indicating the individual’s authority to sign on the patient’s behalf. To request the release of this information, a patient’s legal representative or insurance company must also provide this consent.

To receive information from Fire Incident Reports:

Montgomery County Fire and Rescue Services
Office of Quality Assurance
101 Monroe Street
12th Floor
Rockville, MD 20850

Questions: (240) 240-777-2418

Please provide:

1. a stamped, self-addressed business size envelope;
   
2. the date the fire occurred;
   
3. the approximate time of the fire;
   
4. the name of the property owner(s);
   
5. the location or address where the incident occurred; and
   
6. the requestor’s signature on a document requesting the report.
   
   
   Information will be provided to you within 30 days of the receipt of an acceptable request that complies with the requirements indicated above.