Patient Care Report FORM (EMS)

A Patient Care Report is generated whenever Collierville Fire Department assists a sick or injured person. These reports contain confidential personal health information (PHI) and are not part of the public record. 

Copies of Patient Care Reports are available to our patients, their representatives and others as specified by Tennessee Code Annotated (TCA). The Fire Department's policies and procedures for the release of patient care reports comply with restrictions specified under state law. At the same time, the Fire Department strives to make the process of obtaining copies of records as easy as possible for those seeking them.

The fee for a Fire Incident Report is $10; cash, check or money order, payable to the town of Collierville
 
You can request a copy of a Patient Care Reports by either contacting the Fire Records Administrator or submitting your request electronically with the form below.  

Renee Langley, Fire Records Administrator
1251 Peterson Lake Road, Collierville, TN 38017
rlangley@ci.collierville.tn.us or (901) 457-2481 
Mon--Fri 7am-4pm (excluding holidays)

Patient Care Report Request

 
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    • (street address, intersection, etc.)
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    • (structure fire, vehicle fire, etc.)
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    • Requires driver's license or equivalent photo ID.
    • Requires driver's license or equivalent photo ID.
    • Requires driver's license or equivalent photo ID, a copy of document that designates you as court-appointed guardian, custodian or representative, states the time period for which the authorization will be valid, which may not exceed one year. Authorizations missing any of the required elements will not be accepted.
    • Requires driver's license or equivalent photo ID, copy of legal document identifying you as personal representative, states the time period for which the authorization will be valid, which may not exceed one year. copy of the Death Certificate. Authorizations missing any of the required elements will not be accepted.
    • Submit a letter of request on your letterhead, along with a copy of the document by which the patient has appointed you to represent him or her. The letter of request must contain the patient's name, incident date, incident time and incident location and states the time period for which the authorization will be valid, which may not exceed one year. Authorizations missing any of the required elements will not be accepted.
    • You may send a letter of request on your letterhead that includes the patient's name, incident date, incident time, and incident location, the reason the record is being requested, along with a copy of the document by which the person authorized to consent to health care has appointed you to represent him or her, a copy of the document by which the person is authorized to consent to health care, states the time period for which the authorization will be valid, which may not exceed one year. A person authorized to consent to health care for an adult who requests a copy of medical record is a person in interest when 'consistent the the authority granted.' Authorizations missing any of the required elements will not be accepted.
    • You may provide a letter on your letterhead that includes the patient's name, incident date, incident time and incident location, affirms the parent-child relationship, affirms that the parent's authority to consent to health care for the minor has not been specifically limited by a court order or a valid separation agreement entered into by the parents, states the time period for which the authorization will be valid, which may not exceed one year. Provide a copy of the document stating that the parent has appointed you to represent him or her. Authorizations missing any of the required elements will not be accepted.
    • Send a letter of request on your letterhead that includes the patient's name, incident date, incident time and incident location, along with a copy of the court order appointing the person as the guardian, custodian or representative of the minor, states the time period for which the authorization will be valid, which may not exceed one year. You must also include a copy of the document by which the person has appointed you to represent him or her. Authorizations missing any of the required elements will not be accepted.
    • You may send a letter on your letterhead in a request that includes the patient's name, incident date, incident time and incident location, along with a copy of the document by which the duly appointed personal representative has appointed you to represent him or her, a copy of the document by which the person is the duly appointed personal representative, states the time period for which the authorization will be valid, which may not exceed one year, a copy of the Death Certificate. Authorizations missing any of the required elements will not be accepted.




Collierville Fire Department:
 1251 Peterson Lake Road, Collierville, TN 38017 | (901) 457-2400 | Emergency: 9-1-1

© 2018 Collierville Fire Department. All rights reserved.  AP&D  Content (data and photography) contained herein is the property of the Collierville Fire Department and/or the individual(s) who provided the imagery or data for usage and is to be considered protected by copyright. Content is maintained by individual departments. Every effort has been made to ensure the accuracy of the information within this website. Collierville Fire & Rescue and The Town of Collierville do not discriminate on the basis of race, color, national origin, age, sex, or disability in their hiring and employment practices, or in admission to, access to, or operation of its programs, services, and activities pursuant to Title VI of the Civil Rights Act of 1964 (42 U.S.C. 200d) and the Americans with Disabilities Act of 1990, Pub. L 101-336