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2. 
4. First Name of Requestor*
5. Last Name of Requestor*
7. Records Requested on Behalf Of (Name of person, agency/ company, etc.)

   Please complete the following section if you are requesting records on behalf of another individual, agency, or for your employer.

9. Address*
11. City*
12. State*
13. Zip Code*
15. Phone Number*
16. Email Address*
18. Date of Record
    (If Known)
    Date of Record
    (If Known)
19. Description of Requested Record(s)*
21. Records Requested

    Please describe the records you are requesting and any additional information that will help us locate them for you as quickly as possible. Failure to provide information sufficient to identify the records may cause delay.

    If you request medical records for a deceased "Descendent", WA State law (RCW 70.02.140, RCW 7.70.065) identifies a statutory priority among individuals with authority to consent to release a decedent's medical records. Before we can release the records to you, we need to confirm you are eligible. 

    Support Documentation/ Verification Needed:

    • Letters of Testamentary or Letters of Administration - If a personal representative is appointed for a descendant's estate, the medical records can only be released with the personal representative's authorization. Or,
    • Durable Power of Attorney - If a descendant had durable power of attorney in effect at the time of death, the medical records can only be released to the attorney named under the power of attorney.
    • Surviving spouse or Family Member (Child, Grandchild, Niece, Nephew, Aunt, Uncle, or parent (who is 18+ years of age) - all surviving family members must agree to the consent of release. 

    By Signing this form, and requesting records for a dependent, the undersigned declares under penalty of perjury of the laws of the State of Washington that the above information and any submitted and attached documentation is true and correct.

23. Descendant Options

    Write-in the applicable descendant (Personal Representative, Guardian, Durable Power of Attorney, Spouse, Child (18+), Parent, Sibling (18+), Grandchild (18+), Niece or Nephew (18+), Aunt or Uncle (18+).

24. If applicable, I am requesting records of a descendant (as defined by the law) as a:
26. Upload Supporting Documents & Release Forms
28. Electronic Signature Agreement*

    By signing this form, the undersigned hereby requests records for themselves, their employer, on behalf of a patient, or on behalf of a dependent. The undersigned affirms under penalty of perjury under the laws of the State of Washington that all information provided in this request, including any submitted or attached documentation, is accurate and complete to the best of their knowledge.

    1. I agree.
30. Electronic Signature*
32. Acknowledgment of Fees and Use of Records

    I understand that there may be fees for duplicating the records requested. The charge is a minimum of $0.20 per page. Additionally, the District's Records Disclosure Policy is available for review.

    I acknowledge that if I do not pay for the costs associated with this request, I will need to settle any outstanding charges before any future requests can be processed.

    I also certify that any lists of individuals obtained through this request will not be used for commercial purposes.

34. Signature*
35. Date*
    Date
37. Requests

    If you are unable to submit your Public Records request electronically, please send a written request to:

    Mountain View Fire and Rescue
    Attn: Public Records Request Officer
    32316 148th Avenue SE
    Auburn, WA 98092

    The Public Records Officer will be responsible for ensuring compliance with the Public Records Act. However, another staff member of the Fire District may handle the processing of the request. For clarity, references to the Public Records Officer may include their "designee." The Public Records Officer or designee, along with the Fire District, will provide the "fullest assistance" to requestors, ensure that public records are safeguarded against damage or disorganization, and prevent the fulfillment of public records requests from excessively disrupting the essential functions of the Fire District.

    To request an appointment to review records, duplicate or paper copies of records, please email the original request, previously provided communication and documents to info@mvfire.org.

39. Acknowledgement of Request

    In accordance with RCW 42.17.320, this form confirms that your request has been received. The District anticipates providing a response within 21 days, or as soon as a determination regarding disclosure, denial, or exemption can be made. Please note that the District reserves the right to extend this timeframe if needed.

41. Discovery Request or Compulsory Process

    (1) Prior to serving a discovery request or compulsory process on a health care provider for health care information, an attorney must give advance notice to both the health care provider and the patient or the patient's attorney. This notice should be delivered via service of process or first-class mail and must include:

    • The identity of the health care provider from whom the information is requested
    • The specific health care information being sought
    • The deadline by which a protective order must be obtained to prevent the health care provider from disclosing the information

    The deadline must allow sufficient time for the patient and health care provider to seek a protective order, but it must be at least 14 days from the date the notice is served or delivered. The discovery request or compulsory process can then be served on the health care provider.

    (2) Without the patient's written consent, a health care provider cannot disclose the requested health care information if the requestor has not followed the procedures outlined in subsection (1). If no protective order has been issued by a competent court preventing compliance, the health care provider must disclose the information according to this chapter. Any compliant discovery or compulsory process must be added to the patient's record.

    (3) The production of health care information under this section does not, by itself, waive any legal privilege, objection, or defense that may exist under other laws or rules of evidence or procedure.

43. References
    • RCW 70.02.150
    • RCW 7.70.068
    • RCW 70.02.070
    • RCW 42.56.556
    • RCW 70.02.060
    • RCW 42.17.320
45. Records Request Completion Notice

    The email response containing the requested records will be sent after this form is submitted and will serve as notice of completion for your specific request.

    Once the records are shared, Mountain View Fire and Rescue will have fulfilled the search for records related to this request and provided all relevant documents. Consequently, this request will be considered closed.

    According to RCW 42.56.550(6), you have one year from the date of receiving the records to seek judicial review of this request and we will not intend to produce additional records or further address the request. 

    If you have any questions about this request or response, or believe additional records have not been provided, you may submit follow-up questions with regards to your request within ten (10) business days of the date records were shared, by emailing info@mvfire.org. In your request, please include the original Records Request form, any and all records already provided/ received, and a list of any additional requested records. 

    Any such follow-up questions will not extend the start date of the statute of limitations unless we formally notify you that we have reopened your request in response to such follow-up.

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46. 1. Receive an email copy of this form.
47. Email address

    This field is not part of the form submission.

48. Submit

* indicates a required field