Fire Report Request

Leave This Blank:

Fire and EMS reports are available by request. Completion of this form will allow for a copy of a report be sent by email and provides the information needed to submit an insurance claim. Please note the report will not include any patient information as it is protected by the Health Insurance Portability and Accountability Act (HIPAA). Fire reports offer minimal information as to the cause of a fire as this is documented in a separate confidential report.

Please feel free to contact 336-229-3133 if you have any questions!
 
* indicates required fields.