2. The St. Lucie County Fire District (SLCFD) Records Department processes all requests for public records generated by the general public and the media. These may include, but not limited to; incident reports, district personnel files, district policies and procedures, data reports, and interoffice memos. To streamline processing, ensure accuracy and track progress, all public record requests must be submitted in writing to the SLCFD Records Department. All requests will be logged and verified; copies of the pertinent records will be obtained and released to the requesting party. A picture ID is required to request records. If you can't upload a picture with this form, you will need to come to the Administrative Office in person to show ID. Our address is 5160 NW Milner Dr. Port St. Lucie FL, 34952.
4. Patient Name:*
5. Date of Birth*
7. Contact Phone number*
9. Address:*
11. City:*
12. State:*
13. Zip Code:*
15. Last Date of Service:
17. Email Address
19. Patient Rights: As a patient, you have the right to access, obtain copies or inspect your protected health information, or PHI, in accordance with federal law. You may also have the right to request an amendment to your PHI, or request that we restrict the use and disclosure of it. These rights are further described in our Notice of Privacy Practices and in other policies which you may have upon request.
21. To better allow us to process your request, please indicate the type of request you are making on this form: (Check all that apply)*

    1. Access to simply review my health information
    2. Access to obtain copies of my health information
    3. Access to review and potentially request amendment of my health information.
    4. Access to review and potentially request an accounting of how my PHI has been used and
    5. Access to review and potentially request restrictions on the use and disclosure of my health
23. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
25. Electronic Signature*
27. Upload Picture ID*
    A picture ID is required to request records.
29. If you are a Power of Attorney, the patient is a minor or the patient is deceased:
    Medical Aid/Transport Records

    Additional documentation is required if you are a Power of Attorney, the patient is a minor, or the patient is deceased. Please see the "Requirements" listed under "Medical Aid/Transport Records" You may upload the additional documents or bring in the copies to our Administrative office. Our address is 5160 NW Milner Dr. Port St. Lucie FL, 34952.
31. Upload Additional Documents
33. Upload Additional Documents
Leave This Blank:


35. 1. Receive an email copy of this form.
36. Email address

    This field is not part of the form submission.

37. Submit

* indicates a required field