PR01 2024-04
FIRE DEPARTMENT – CITY OF NEW YORK
BUREAU OF LEGAL AFFAIRS – PUBLIC RECORDS UNIT
9 MetroTech Center, Brooklyn, NY 11201
publicrecordsunit@fdny.nyc.gov – (718) 999-2681
Pre-Hospital Care Reports
This form is used to request copies of Pre-Hospital Care Reports held by the New York City Fire Department concerning
patients treated or transported by the Bureau of Emergency Medical Services (FDNY EMS). There is no fee to receive
copies of these records.
SAVE TIME: Non-certified copies of these records may be requested and received electronically by submitting this
completed form – along with copies of the required supporting documents – through myPatientEncounters
(https://fdny.mypatientencounters.com/myrecord).
Please read these instructions carefully before completing this request form:
• The FDNY only maintains Pre-Hospital Care Reports for patients treated or transported by FDNY EMS. For
all other patient records, contact the responding ambulance provider or receiving hospital.
o Important: If an invoice was issued for emergency transportation, it will list the name of the ambulance
provider – It might not be the FDNY, and in that case you will need to contact the listed provider.
• If you have a copy of the FDNY invoice for emergency transportation, include the key details from it in the
“FDNY Invoice Details” section of this form (under “Section B”). These billing details are very useful for the
FDNY in identifying the incident.
• Pre-Hospital Care Reports can only be released to parties authorized to receive the records. These are the
categories of patient representatives and acceptable proof:
o PATIENT (SELF)
Acceptable Proof of Identity: Patients must provide a copy of a valid government-issued photo ID.
o PARENT OR GUARDIAN OF A MINOR
Acceptable Proof of Status as Parent or Guardian: Parents and guardians must provide a copy of a valid
government-issued photo ID, along with a copy of either the patient’s birth certificate listing the parent’s
name or a court document indicating custody.
o OTHER AUTHORIZED REPRESENTATIVE
Acceptable Proof of Status as Other Authorized Representative: Other patient representatives must
provide a copy of a valid government-issued photo ID, or name of representing law firm, along with a
notarized letter from the patient authorizing the release of the Pre-Hospital Care Report to this other
person, and a completed FDNY HIPAA Authorization to Disclose Health Information form.
If the patient is deceased, patient representatives must provide a copy of a valid government-issued
photo ID, along with a court record appointing them as executor of the estate (Letters Testamentary /
Letters of Administration).
This completed record request form, along with copies of the required supporting documents, may be submitted:
• Through myPatientEncounters (https://fdny.mypatientencounters.com/myrecord).
• In-person at the FDNY headquarters during regular business hours (weekdays from 8 a.m. – 2 p.m., excluding
holidays).
• By postal mail (must also include a stamped, self-addressed envelope).
PR01 2024-04
Section A
Customer Information (may differ from “Patient Information”)
_______________________________________________________________________
Name
_______________________________________________________________________
Address
____________________________________ ________________ ________________
City State Zip Code
Relationship to the Patient
PATIENT (SELF)
PARENT OR GUARDIAN OF A MINOR
OTHER AUTHORIZED REPRESENTATIVE
_____________________________________________
Telephone Number
Section B
Patient Information
________________________________________________________________________
Patient Name
___________________________________ ___________________________________
Date of Birth Last Four Digits of Social Security Number
AM
___________________________________ _____________________________ PM
Incident Date Incident Time
________________________________________________________________________
Incident Address
______________________________________________________ ________________
Incident Borough Zip Code
________________________________________________________________________
Receiving Hospital (if applicable and known)
________________________________________________________________________
Notes
FDNY Invoice Details (if known)
_____________________________________________
ACRPCR #
_____________________________________________
Invoice #
_____________________________________________
AC ID #
FDNY Use Only
_____________________________________________
Received
_____________________________________________
Processed
