GOLDER RANCH FIRE DISTRICT~ RECORDS REQUEST FORM

Document Type Requested: *

Paper Copy .25 cents/page | Pick up in-person
Send by mail plus postage
Email
Electronic file access
Flash drive sent by mail plus postage
Flash Drive $5.00 | Pick up in-person

Requestor Information: Is this records request for a commercial purpose: (Check One) *

Yes
No

Fees for commercial records requests include market value of the records, time to retrieve/compile the records & records per page fee. A.R.S. 39-121.03 D. For the purpose of this section, “commercial purpose” means the use of a public record for the purpose of sale or resale for the purpose of producing a document containing all or part of the copy, printout or photograph for sale or the obtaining of names and addresses from public records for the purpose of solicitation or the sale of names and addresses to another for the purpose of solicitation or for any purpose in which the purchaser can reasonably anticipate the receipt of monetary gain from the direct or indirect use of the public record. Commercial purpose does not mean the use of a public record as evidence or as research for evident in an action in any judicial or quasi-judicial body.

Date of Request: *

Reason for Request: *

Requestor Name: *

First

Last

Requestor Address: *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Phone No: *

Environmental Report/Fire Code Violation Inquiry:

Property Address:

Information Requested:

Fire Report:

Date / Time of Incident:

Date

Time

Incident Address:

Medical Report:

Information Requested:

Medical Report
Bill
Both

Patient's Full Legal Name:

Date of Incident:

Incident Address:

Address Line 1

City

State

Zip Code

Special Note for Medical Record Request (ANY un-redacted record that contains a patient’s protected health information): Patients requesting medical records must provide proof of identification (government issued photo I.D.). Third parties requesting a patient’s medical record must provide (1) a notarized HIPAA– compliant release, per 45 C.F.R. §164.508 signed by the patient; or (2) a court order signed by a judge authorizing release (45 C.F.R. §164.512). A subpoena without a HIPAA-compliant release or court order is not sufficient. (3) government issued photo I.D. of the patient. For questions call (520) 825-9001 or email: records@grfdaz.gov.