Name*

Phone Number
Fax Number
Company
Street Address
City
State
Zip Code
Email *
Please: Mail report     Hold report for pick-up    Fax report    Email report   

TYPE OF REQUEST *
Building/House Fire     Vehicle Fire    HazMat    Data & Stats    Other

REQUEST DETAILS (Please be specific and, if applicable, include date, time, and incident location)

Emergency Medical Service (EMS) records should include a Health Insurance Portability and Accountability Act (HIPAA) authorization form completed and signed by the patient or their legally authorized representative. 

Template forms are available at Fairfax County HIPAA Authorization Form

A completed form can be submitted via email to fire.foia@fairfaxcounty.gov or sent via fax to 703-246-6096.