There is a $6.50 fee per record. (No charge to a patient requesting their own record.)

Mail check and form to: Tempe Fire Medical Rescue Department
    P.O. Box 5002, Mail Stop 11‐1, Tempe, AZ 85280
Or
Email form to: EMSrecords@tempe.gov then call 480‐858‐7200 to pay by credit card.

Questions? Call 480‐858‐7264 or email EMSrecords@tempe.gov

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Please provide the information below.

Please provide the information below.

Today's date:

Requested by:

Company Name:

Mailing Address:

City:

State:

Zip Code:

Phone Number:

Email:

Patient's Name:

Patient's DOB:

Incident # ( if known )

Date and Time of Incident:

Address or Crossroads of Incident:

Type of Incident:

Note: HIPAA laws require additional information for medical records release.

Records are typically processed within two weeks. Questions call Monique Rodriguez at 480‐858‐7264.

1. To receive a copy of your submission, please fill out your email address below and submit.
2. Email Address

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