Protection of Patient Information

The Montecito Fire Department makes every effort to protect the private health information (PHI) of individuals to whom the department provides services. 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

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Patient Information

Patient Name (required)

Patient Date Of Birth (required)

Patient Address (required)

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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.

Date & Time of Incident (required)

Incident Number (required)

Incident Address (required)

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Requesting Party Information

Name (required)

Title (required)

Badge # (if applicable) (required)

Phone Number (required)

Work Email Address (required)

Agency Name (required)

Work Address (required)

City (required)

State (required)

Zip Code (required)

I am Making This Request for Protected Health Information (PHI) in my Capacity as: (required)

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)

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)

Other

Reason for Request (required)

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

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Basis for Requested Disclosure of Protected Health This Request is Being Made Pursuant to One of the Following Exceptions:

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

1. Written Authorization of the Patient. [45 CFR §§ 164.508(c)(1)-(4)]

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)]

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)]

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)].

5. Disclosure to Law Enforcement for Limited Identification and Location of Suspect, Fugitive, Material Witness or Missing Person. [45 CFR § 164.512(f)(2)].

6. Disclosure to Law Enforcement in Response to a Request About an Individual Who is Suspected to be a Crime Victim

Attach Relevant, Supporting Documentation (i.e. Written Authorization of Patient, Court Order, Court-Ordered Warrant, Judicial Subpoena or Summons, Grand Jury Subpoena, Specific Citation)

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

Your Signature (required)

Confirm e-Signature

Review Electronic Records and Signatures Policy (required)

Read our Electronic Record and Signature Disclosure

I agree to use electronic records and signatures

Date (required)

Email Address (required)

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Thank you, your submission has been received.

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.

Fee for Printed Incident Information

There is no fee for digital copies.

$24.00 (up to 10 printed 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.