Medical Records Request Form - Law Firms/Insurance

Please use this form to request medical and billing records only. If you need to provide insurance information, please do not submit this request. Instead, contact Digitech by using their website: https://digitechcomputer.com/contact-us/ or by phone: 844-378-2134. Please note: the records are sent via secure email, encryption, to open the records you will be prompted to enter a onetime passcode, which will be emailed to you separately by Microsoft. If you are working off a Mac computer you will not be able to open the records, this requires a Windows based computer. FEES: A person granted the right to inspect SMFR records will not be charged a fee when the processing time to fulfill the records requests takes less than one hour. When processing time takes more than one hour, fees may be charged in accordance to South Metro's Open Records Policy (see page 4 for detailed fee information).


Medical Records Request Policies:

South Metro Fire Rescue's Open Records Policy (pdf) located: https://www.southmetro.org/DocumentCenter/View/1644/Open-Records-Requests South Metro Fire Rescue's Resolution Adopting the Protections of Consumer Data Privacy Policy (pdf) located: https://www.southmetro.org/DocumentCenter/View/1800/SMFRA-Resolution-No-2018-10-Adopting-the-Protections-for-Consumer-Data-Privacy-Policy---Signed

By checking this box you confirm you have read the above Open Records and Protection for Consumer Data Privacy policies.


Request Fulfillment:

Every effort is made to respond to your request within 72 business hours. If you have questions, please email Merilee.James@southmetro.org. Please note: the records are sent via secure email, encryption, to open the records you will be prompted to enter a onetime passcode, which will be emailed to you separately by Microsoft.

Requesting Information

You may request information for one (1) incident, location, etc. per form. Multiple requests must be submitted separately.

Requestor Information

Select
Caret IconCaret symbol
Do you hold legal power of attorney for the subject involved?*

Please choose one or more from the drop down list

Transport or Treatment Records
Caret IconCaret symbol

If applicable

Phone

Incident Information

South Metro Fire Rescue (SMFR) has multiple databases due to mergers and software changes, we require a specific date(s) of service to process any medical and billing record requests as it is one of the 3 required identifying markers we use for verification of PHI (Protected Health Information). Additionally, SMFR only retains medical records for 7 years.

Date of Incident or Event

If known

Enter name(s)

You may provide additional information regarding your request here.

Did the incident pertain to the death of the subject involved?*

Required Documentation

Upload documents below to complete your request. You must provide ALL necessary documents to complete your request. Check the appropriate boxes below when you have attached the files. The SMFR release form can be found here: http://www.southmetro.org/DocumentCenter/View/1847

Drag and drop files here or