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:
Please attach a photocopy of the requesting party's agency identification card with photograph along with this form.
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)].
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)].
I Certify Under PENALTY OF PERJURY That the Foregoing is True and Correct.
$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.
This field is not part of the form submission.
* indicates a required field