CANON CITY AREA FIRE PROTECTION DISTRICT
RECORDS REQUEST FORM
COLORADO OPEN RECORDS ACT (CORA)
Date: __________________________
Requestor's Name: _______________________________________________________
Organization Represented (if any): ___________________________________________
Address: _______________________________________________________________
Telephone: __________________________ Fax: ______________________________
Email: _________________________________________________________________
Name of specific document(s) requested:
FILING INSTRUCTIONS: You may fill out the form and return it via email to records_request@canonfire.org, or by mail or in person to the Canon City Area Fire Protection District, 3016 E. Main Street, Canon City, CO 81212.
FOR OFFICAL USE ONLY:
Record request received by: ___________________Date: ____________Time: _______
Date ready: ______________________________ Number of pages: ________________
Date requestor was notified: _________________ Date reviewed: __________________
Staff time to retrieve/Copy records: __________________________________________
Staff time fee: $__________ Copy fee: $__________ Total fees due: $_____________
Date request closed: ______________________________________________________
Additional comments: _____________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
INSTRUCTIONS FOR RECORDS REQUESTS
1. Provide a brief, but specific, description of the document(s) or information requested, noting the date of the incident or issuance/adoption of the document if known. A request that is broad, vague, or too voluminous may cause a delay in the time required to produce the records, or a denial of the request .
2. All requests must be submitted to: Canon City Area Fire Protection District (District), 3016 E. Main Street, Canon City, CO 81212 or via email at records_request@canonfire.org. All requests must be submitted on the District "RECORDS REQUEST FORM", which is available at the above listed address. Requests for the release of medical information shall use the appropriate "Release of Medical Information" form for either a private party or law enforcement request.
3. If the records are available pursuant to C.R.S. §24-72-201, the records shall be made available for inspection within three (3) business days. If extenuating circumstances exist that the records cannot be gathered within the three (3) day period, the period shall be extended an additional seven (7) business days. The requestor shall be notified of the extension within three (3) business days of receiving the request.
4. Upon receipt of the request, we will begin collecting the records requested and notify the requestor when completed. We will schedule a time for review and inspection of the records. Reviews will take place during regular business hours (Monday - Friday, 8:00 - noon and 1:00 - 5:00, except holidays) at 3016 E. Main Street, Canon City, CO 81212, unless another location is designated by the District.
5. The requestor may take written notes and/or use a portable computer. Outside photocopiers and scanners are not allowed.
6. Costs associated with researching, preparing, and copying documents is as follows:
· Black and white document copies (letter or legal) are $0.25 per page.
· Color copies will be charged actual cost.
· Electronic document delivery is $0.25 per page, plus $5 per CD if requested.
· If actual costs exceed $0.25 per page, actual costs may be charged.
· Any postage will be charged at the actual rate for weight and size.
· Staff time to research and assemble requested records, or convert a document into format for retrieval, will be charged at actual personnel rate, with the first 30 minutes at no charge.
7. You will be notified in advance of any applicable fees that may be incurred relevant to item #6 listed above. We will not compile the records request on your behalf without your prior approval and advance payment. Some requests will require an estimate of anticipated costs, which will require initial payment in that amount. Upon the completion of the request, the cost difference will either be refunded or additionally charged, prior to the release of the copied records. We can not accept credit cards or bill for services. Payment must be made in advance in the form of cash or check made payable to the Canon City Area Fire protection District.
8. In the event the requestor does not make arrangements for a review of the documents, fails to appear for the review, or fails to prepay for the costs within 3 business days of notification of availability of records, the request will be deemed closed. Any further request will be deemed a new request and must be resubmitted.
PRIVATE PARTY REQUEST FOR RELEASE OF MEDICAL INFORMATION
I hereby request the Cañon City Area Fire Protection District release the below identified confidential Emergency Medical Services (EMS) information for the following person.
Patient Name: Location of Incident:
Date of Incident: Time of Incident:
The Health Insurance Portability and Accountability Act (HIPAA) govern the release of medical records. In order to fill a records request for Emergency Medical Services (EMS) information, one or more of the following criteria must be met (check appropriate box, then copy and attach proof to this release).
This request for release is made via,
q Requestor is the patient and can provide proof of identification as required below
q Requestor has a notarized power of attorney for the patient.
The patient is 18 years of age or older with one of the following:
q Requestor is the patient and has a government issued photo ID.
q Requestor has a notarized authorization from the patient and copy or original government issued photo ID from the patient and a government issued photo ID of the requestor.
The patient is under 18 years of age; one of the following is required:
q Requestor is the custodial parent of the child, has an official birth certificate of the patient and a government issued photo ID of the requestor.
q Requestor has an original or notarized copy showing Court appointed guardianship of the patient and a government issued photo ID of the requestor
q Requestor is not a parent of the child, but has one of the above criteria of documentation and a notarized letter stating the parents or guardian allows the requestor to have the information.
I understand that by authorizing the release of these records, I am waiving and relinquishing any privilege or right that I may have to keep said records confidential or prevent their disclosure; and I hereby agree: to hold the Cañon City Area Fire Protection District and all of its officers, employees and agents harmless and indemnify them from any and all claims that may be made against them on account of the release of the below-described records as herein authorized.
I hereby affirm that the above facts and representations are true and correct.
Requestor’s Signature Date
Printed Name
District employee executing release:
Date: Initials:
Method of Delivery: Fax Hand delivered to: _______ __ _____ (Signature)
Mailed to following address: ________