Public Records Request Form

Name (required)

Date (required)

Email Address (required)

Phone Number (required)

Detailed Description of Records Requested (required)

If any records requested contain Protected health Informaiotn (PHI) about a person who is not you, this request must be accompanied by an Authorization to Release medical Information under the Health Insurance Portability and Accountability Act of 1996 (HIPPA)

An Authorization to Release Medical Informatin is attached (required)

Yes

Preferred Delivery Method (required)

Email*

Fax*

Mail

Pick Up / View in Person

*Records sent by email or fax transmission will be sent through UNENCRYPTED FAX/EMAIL THAT IS NOT SECURE and there is a risk that the records could be seen by a thrid party during electronic transmission, while in electronic storage, and/or upon completed delivery. The District is not responsible for unathorized access of Protected Health Information (PHI resulting from the faxed or emailed transmission, or for safeguarding PHI upon delivery.

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