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Request for Release of Incident Report Information

2. Requester Information

4. First Name*

5. Last Name*

7. Email Address*

8. Agency Name (If Applicable)

10. Address*

12. City*

13. State*

14. Zip Code*

16. Phone Number*

17. Driver's License No.

19. Protection of Patient Information
    The City of Napa Fire Department makes every effort to protect private health information (PHI) of individuals that the department provides services to. The release of this information can only occur with the written authorization of the patient, a representative authorized by the patient, or by court order.

    The City of Napa Fire Department makes every effort to protect private health information (PHI) of individuals that the department provides services to. The release of this information can only occur with the written authorization of the patient, a representative authorized by the patient, or by court order.

23. Incident Information
    To better allow us to process your request, please indicate on this form the reason for your request and the type of incident information you want to receive.

    To better allow us to process your request, please indicate on this form the reason for your request and the type of incident information you want to receive.

25. Reason for Request*

27. Incident Address*

28. Incident Number

30. Date of Incident*
    Date of Incident

    Date of Incident

32. You will be contacted by a Fire Department representative within one (1) week of receipt of this request form, you will be notified as to the status of your request.

34. Fee for Incident Information
    $20.00 (up to 10 pages – each additional page $.38) Fee will be collected at time of release of incident information/report. Note: Victims of crimes receive one copy free of charge.

    $20.00 (up to 10 pages – each additional page $.38) Fee will be collected at time of release of incident information/report. Note: Victims of crimes receive one copy free of charge.

Leave This Blank:


36. 1. Receive an email copy of this form.
37. Email address

    This field is not part of the form submission.

38. Submit

* indicates a required field