Form Center

2. 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 release of PHI to a law enforcement agency is permitted under the following circumstances:

   1. In response to a law enforcement officer who completes the department’s release of PHI to law enforcement form and requires the PHI (45 CFR 164.512(f)(1)):
      1. To report certain types of wounds or other physical injuries.
      2. In compliance with a court order or court-ordered warrant, subpoena, or summons, a grand jury subpoena, or an administrative request.
   2. In response to a law enforcement officer who completes the department’s release of PHI to law enforcement form for the purpose of identifying or locating a suspect, fugitive, material witness, or missing person. In such a case, the Department may only disclose the following PHI (45 CFR 164.512(f)(2)):
      1. Name and address
      2. Date and place of birth
      3. Social Security number
      4. ABO blood type and Rh factor
      5. The character and extent of injuries
      6. Date and time of treatment
      7. Date and time of death, if applicable
      8. A description of distinguishing physical characteristics

6. Patient Information
8. Patient Name*
9. Patient DOB*
   Patient DOB
11. Patient Address*
15. 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.
17. Date of Incident*
    Date of Incident

    Date of Incident
18. Incident Number*
20. Incident Address*
24. Requesting Party Information
26. Name *
27. Title*
28. Badge # (If Applicable)
30. Phone Number*
31. Work Email Address*
33. Agency Name*
35. Work Address*
37. City*
38. State*
39. Zip Code*
41. I am Making This Request for Protected Health Information (PHI) in my Capacity as:*

    1. Peace Officer/Police Officer/Detective (Under CA Penal Code § 830.1, Which Discusses the Authority of Peace Officers as to Public Offenses Within Their Jurisdiction)
    2. Internal Affairs Investigator (Under CA Penal Code § 832.5 to Investigate a Complaint from a Member of the Public Against a Peace or Custodial Officer)
    3. Other
43. Title

    Your Title

44. Pursuant to

    Code Citation

46. Reason for Request*
50. Identification Verification

    Please attach a photocopy of the requesting party's agency identification card with photograph along with this form.

54. Basis for Requested Disclosure of Protected Health

    This Request is Being Made Pursuant to One of the Following Exceptions:

56. This Request is Being Made Pursuant to One of the Following Exceptions:

    1. 1. Written Authorization of the Patient. [45 CFR §§ 164.508(c)(1)-(4)]
58. Attach Written Authorization of the Patient*
60. 1. 2. Disclosure to Law Enforcement Because the Nature of the Wound or Physical Injury of the Above-Named Patient / Victim Requires Reporting / Disclosure. [45 CFR § 164.512(f)(1)(i)]
62. 1. 3. Disclosure to Law Enforcement Because a Court Order, Court-Ordered Warrant, Judicial Subpoena or Summons Issued by a Judicial Officer, a Grand Jury Subpoena Has Been Issued. [45 CFR § 164.512(f)(1)(ii)(A) and (B)]
64. Attach Court Order, Court-Ordered Warrant, Judicial Subpoena or Summons, Grand Jury Subpoena*
66. 1. 4. An Administrative Request, Including an Administrative Subpoena or Summons, a Civil or an Authorized Investigative Demand, or Similar Process Authorized Under the Law, Provided That:

    The Information Sought Here is Relevant and Material to a Legitimate Law Enforcement Purpose (i.e., Investigating Crimes, Investigating Police Misconduct, etc). The Request is Specific and Limited in Scope to the Above-Named Patient/Victim, Date, and Incident. De-Identified Information Cannot Reasonably be Used for the Law Enforcement Purpose Stated Above. [45 CFR § 164.512(f)(1)(ii)(C)].

68. Explain How This Information is Relevant and Material, Specific and Limited in Scope. If Citing Specific Citation or Legal Authority
70. Attach Specific Citation or Legal Authority, if Applicable
72. 1. 5. Disclosure to Law Enforcement for Limited Identification and Location of Suspect, Fugitive, Material Witness or Missing Person. [45 CFR § 164.512(f)(2)].
74. 1. 6. Disclosure to Law Enforcement in Response to a Request About an Individual Who is Suspected to be a Crime Victim Where Either:
77. 1. The Suspected Victim's Written Consent to the Disclosure. [CFR § 164.512(f)(3)(i)].
80. Attach Suspected Victim's Written Consent to the Disclosure
83. Or
86. 1. The Suspected Victim's Incapacity and/or Other Emergency Circumstance Prevents the Ability to Obtain his/her Authorization.

    If the Victim's Agreement Cannot be Obtained Due to Incapacity or Other Emergency Circumstance, I Certify That the Information is Needed to Determine Whether a Violation of the Law by Someone Other Than the Victim has Occurred, That the Information is Not Intended to be Used Against the Victim, and That the Investigation Would be Materially and Adversely Affected by Waiting Until the Patient is Able to Agree to the Disclosure. Disclosure is in the Best Interest of the Individual/Suspected Victim. [CFR § 164.512(f)(3)(ii)(A)-(C)].

90. Acknowledgement

    I Certify Under PENALTY OF PERJURY That the Foregoing is True and Correct.

92. Requesting Party Signature*
93. Date*
    Date
97. 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.
99. Fee for Incident Information

    $24.00 (up to 10 pages – each additional page $.39) 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:


101. 1. Receive an email copy of this form.
102. Email address

     This field is not part of the form submission.

103. Submit

* indicates a required field