Test - Northwest Fire District

Date of Request*

Name*

First Last

Email

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Is this request for a commercial purpose?*

Yes
No

If yes, please describe:

Please indicate:*

Fire Report
Medical Report
Vehicle Fire
Donor
Minor
Other

If Other, please explain:

If a Minor, please add Date of Birth*

Date of Incident*

Time of incident*

:

Address of incident

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Name of patient

First Last

Note: According to the Health Insurance Portability Accountability Act (HIPAA), Northwest Fire District is not permitted to disclose and/or release medical information without a signed HIPAA release form from patient (or patient’s properly designated representative). Northwest Fire District may require proof of identity for release of medical information. Third parties requesting a patient’s medical record must attach one of the following: 1) a notarized HIPAA form signed by patient; or 2) a court order signed by a judge authorizing release.

Car make:

Car model:

Model year:

PAYMENT INSTRUCTIONS
Once the Public Record is ready for release, an invoice will be completed and sent to requestor. Please return invoice with payment; records will be released upon receipt of payment and based on the Requestor’s selection below

How would you like the records delivered?*

Mail
Fax
Pick-up
Email

Disclaimer

TIMING
Records may not be inspected at such times and in such manner as to disrupt public business. See Ariz. Att'y Gen. Ops. 180-097, 78-234, 70-1; A.R.S. § 39-121.01(D)(1) ("Any person may request to examine or be furnished copies, printouts or photographs of any public record during regular office hours.") The public is entitled to inspect information within a reasonable time after a request is made. Ariz. Att'y Gen. Ops. 180-097, 78-234, 70-1. Whether time and manner are reasonable must in all cases be a factual determination, depending upon the accessibility of the material. If the information requested is on microfilm and thus requires use of a reader/printer to view it, the time for inspection would depend upon the availability of the necessary equipment. If the requested material has been stored off the premises of the agency, additional time might be necessary to retrieve the document requested. Should this occur, the requesting party should be advised, in writing, of the delay and the reason for it. Similarly, if the requested material contains confidential information that must be redacted, the custodian should inform the requesting party that the response will be delayed and the reason for the delay.
CHARGES
The Legislature has distinguished between the fees an agency may require for commercial and non-commercial requests for copies of public records. A.R.S. § 39-121.01(D)(1) - 121.03(A). A person requesting copies, printouts, or photographs of public records for a non- commercial purpose may be charged a fee for the records. A.R.S. § 39-121.01. An agency may charge a fee it deems appropriate for copying records, including a reasonable amount for the cost of time, equipment, and personnel used in producing copies of records, but not for costs of searching for the records. A.R.S. § 39-121.01(D)(1); Hanania v. City of Tucson, 128 Ariz. 135, 624 P.2d 332 (Ct. App. 1980); Ariz. Att'y Gen. Op. 186-090. If an agency is producing documents pursuant to a subpoena in a civil action to which the agency is not a party, the fee is prescribed by A.R.S. § 12- 351. Persons requesting records for a commercial purpose must describe the purpose for which the records will be used commercially. A.R.S. § 39-121.03(A). When records are requested for commercial purposes, the District may charge additional fees as allowed by the statute. Id.
FORMAT
Public bodies are under no obligation to create special records or change the format of records. Accordingly, if an individual requests records that the District only maintains in paper, it does not have to create an electronic document to satisfy the request. See, Lake v. City of Phoenix, 222 Ariz. 547, 218 P .3d 1004 (2009). CONFIDENTIALITY/DUTY TO REDACT There are over 300 Arizona and federal statutes that address the confidentiality of records, as well as numerous Arizona court cases which establish rules protecting individual privacy and the best interests of the agency. When confidential and public information are comingled in a single document, a copy of the document may be made available for public inspection with the confidential information redacted or excised. Carlson v. Pima County, 141 Ariz. 487, at 491 (1984); see also KPNX-TV v. Superior Ct., 183 Ariz. 589 at 594 (Ct. App. 1995). If confidential material has been attached to an otherwise disclosable document, the material so attached may simply be removed. Ariz. Att'y Gen. Ops. 186-090, 185-097.

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