Manchester, Connecticut

Incident and Patient Care Reports

AUTHORIZATION TO RELEASE PATIENT CARE REPORT

If you were medically treated by personnel of Manchester Fire-Rescue-EMS (MFRE) Department, you, or an agent specified by you, have the right to obtain a copy of the Patient Care Report (PCR) that was generated. A copy of your PCR will be released provided:
 
[1] You, the subject (patient) of the PCR, appear personally in the Office of the Fire Chief of MFRE, complete an "Authorization to Release Medical Information" and be further prepared to offer current valid photo identification that establishes you are the patient referred to in the PCR, or
 
[2] You complete an "Authorization to Release Medical Information" and you, or your agent, forward a notarized original form to the Office of the Fire Chief of MFRE, or
 
[3] You, with Power of Attorney, complete an "Authorization to Release Medical Information" and forward a notarized original form to the Office of the Fire Chief of MFRE along with a copy of the Power of Attorney, or
 
[4] You, an adult with authority to act for a minor patient, complete an "Authorization to Release Medical Information" and forward a notarized original form to the Office of the Fire Chief of MFRE.
 
[5] Cash or check, made payable to Manchester Fire-Rescue-EMS, in the amount of $2.50 per report, to be received upon receipt of report.
 
Upon receipt of a properly completed Authorization to Release Medical Information the Keeper of Records will provide that a true copy of the requested PCR be produced within thirty (30) days.

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REQUESTING A FIRE / INCIDENT REPORT

BY MAIL / FAX / E-MAIL:
You must provide the following information:

1. Completed Incident Report Request Form
2. A legal sized self-addressed stamped envelope, if you would like the report mailed to you

PLEASE NOTE:  There is a report fee of $0.50 per page.  We will contact you with the final cost as soon as the report is completed.
 
Send your request to:
Manchester Fire-Rescue-EMS
Keeper of the Records
75 Center Street
Manchester, CT 06040
Fax: (860) 647-3268