Form PR1 "Ambulance Call Report/ Prehospital Care Report Request Form" - New York City

What Is Form PR1?

This is a legal form that was released by the New York City Fire Department - a government authority operating within New York City. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2008;
  • The latest edition provided by the New York City Fire Department;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form PR1 by clicking the link below or browse more documents and templates provided by the New York City Fire Department.

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Download Form PR1 "Ambulance Call Report/ Prehospital Care Report Request Form" - New York City

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FIRE DEPARTMENT – CITY OF NEW YORK
Public Records Unit / ACR Section
9 MetroTech Center
Brooklyn, New York 11201-3857
(718) 999-1998 or 1999
Ambulance Call Report/
Prehospital Care Report
Request Form
SECTION A
CUSTOMER INFORMATION
Please print the required information below.
___________________________________________________
__________________________
Name
Telephone Number
___________________________________________________
Address
___________________________________________________
State
Zip Code
Note: Please make sure you complete this form and attach all required documents. Enclose a check or money order made payable to
the NYC Fire Department and a stamped self-addressed envelope (with postage). Mail checks or money orders directly to the
address and unit listed above. Only money orders or checks will be accepted for Requests (no exceptions). DO NOT MAIL CASH.
SECTION B
PATIENT INFORMATION
Please carefully read the instructions below and print the required patient’s information.
Name of Patient:
________________________________________________________________
Incident / Date:
____/____/____
Incident / Time:
______: ______
AM
PM
Incident / Location:
________________________________________________________________
Incident / Borough:
________________________________________________________________
Hospital taken to:
________________________________________________________________
Is the patient a minor (please check only one box)?
YES
NO
Date of Birth: _____/ ____/_____
Last 4 digits of Social Security Number:
________________________
If you have the ACR/PCR, please provide ACR/PCR number: _________________________
What is the requester’s relationship to the patient (please check only one box below)?
Self / Patient
Parent / Guardian
Executor / Administrator of Estate
Other ______________________
CUSTOMER – PLEASE READ AND SUBMIT THE REQUIRED ITEM(S) BELOW
An original notarized letter from the patient authorizing the release of this information.
Proof of parental status or guardianship, if the patient is a minor. Acceptable proof is a copy of the patient’s birth
certificate or a court document showing custody / guardianship.
Proof that a court has appointed you executor or administrator of the patient’s estate, if the patient is deceased
(Letters testamentary or letters of administration).
Payment in the form of a check or money order in the amount of $2.25 for each report.
PR1 (July-08)
FIRE DEPARTMENT – CITY OF NEW YORK
Public Records Unit / ACR Section
9 MetroTech Center
Brooklyn, New York 11201-3857
(718) 999-1998 or 1999
Ambulance Call Report/
Prehospital Care Report
Request Form
SECTION A
CUSTOMER INFORMATION
Please print the required information below.
___________________________________________________
__________________________
Name
Telephone Number
___________________________________________________
Address
___________________________________________________
State
Zip Code
Note: Please make sure you complete this form and attach all required documents. Enclose a check or money order made payable to
the NYC Fire Department and a stamped self-addressed envelope (with postage). Mail checks or money orders directly to the
address and unit listed above. Only money orders or checks will be accepted for Requests (no exceptions). DO NOT MAIL CASH.
SECTION B
PATIENT INFORMATION
Please carefully read the instructions below and print the required patient’s information.
Name of Patient:
________________________________________________________________
Incident / Date:
____/____/____
Incident / Time:
______: ______
AM
PM
Incident / Location:
________________________________________________________________
Incident / Borough:
________________________________________________________________
Hospital taken to:
________________________________________________________________
Is the patient a minor (please check only one box)?
YES
NO
Date of Birth: _____/ ____/_____
Last 4 digits of Social Security Number:
________________________
If you have the ACR/PCR, please provide ACR/PCR number: _________________________
What is the requester’s relationship to the patient (please check only one box below)?
Self / Patient
Parent / Guardian
Executor / Administrator of Estate
Other ______________________
CUSTOMER – PLEASE READ AND SUBMIT THE REQUIRED ITEM(S) BELOW
An original notarized letter from the patient authorizing the release of this information.
Proof of parental status or guardianship, if the patient is a minor. Acceptable proof is a copy of the patient’s birth
certificate or a court document showing custody / guardianship.
Proof that a court has appointed you executor or administrator of the patient’s estate, if the patient is deceased
(Letters testamentary or letters of administration).
Payment in the form of a check or money order in the amount of $2.25 for each report.
PR1 (July-08)