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Request Records
At Maplewood Fire & EMS, there are three types of report you could obtain: Fire Report, EMS Report and Ambulance Billing Report. Almost anyone could request copies of reports for legal purposes, but the requirements are different for:
- Patient
- Third-party Requestor (such as: a family member, attorney, insurance claims agent)
- Medical Records - I am the PATIENT
- Medical Records - THIRD-PARTY REQUESTOR
- Ambulance Billing Report
- Fire Report
A signed authorization is required in order to release private health information.
What You Need To Do:
1. Complete the form: Authorization for Release of Protected Health Information.
2. Required: Notarized signature.
3. Copy of your valid driver's license.
4. Drop off, mail or fax the completed form and documentation to the Maplewood Fire Department.
Address: Maplewood EMS
ATTN: Medical Record
1955 Clarence Street
Maplewood, MN 55109
Fax: 651-249-2809
If you are a family member, an attorney or an insurance claims agent, then you are a third-party requestor.
A signed Minnesota Standard Consent Form is required in order to release any private health information.
NOTE:
Any stand-alone signed authorization of release form from your office will not be sufficient, and your request will be denied. What You Need To Do:
1. Required: Complete the form Minnesota Standard Consent Form.
2. Drop off, mail or fax the completed form and documentation to the Maplewood Fire Department.
Address: Maplewood EMS
ATTN: Medical Record
1955 Clarence Street
Maplewood, MN 55109
Fax: 651-249-2809
Address: TransMedic
ATTN: Billing Request
33 wentworth Avenue
Suite 380
West St. Paul, MN 55118
Fax: 651-450-7128
What You Need To Do:
1. Complete the form: Fire Incident Report Request
2. Copy of your valid driver's license
3. Drop off, mail or fax the completed form and documentation to the Maplewood Fire Department.
Address: Maplewood EMS
ATTN: Medical Record
1955 Clarence Street
Maplewood, MN 55109
Fax: 651-249-2809