Form Center

By signing in or creating an account, some fields will auto-populate with your information and your submitted forms will be saved and accessible to you.

Law Enforcement Request for Protected Health Information

  1. 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

  2. Patient Information
  3. 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.
  4. Requesting Party Information
  5. I am Making This Request for Protected Health Information (PHI) in my Capacity as:*
  6. Your Title

  7. Code Citation

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

  9. Basis for Requested Disclosure of Protected Health

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

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

    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)].

  11. Or

    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)].

  12. Acknowledgement

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

  13. 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.
  14. 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.

  15. Leave This Blank:

  16. This field is not part of the form submission.