PUBLIC RECORDS REQUEST FLOW CHART Step 1. Provide Proper Records Request Form to the requestor v Make sure it s filled out completely v Make sure its signed v Payment is due at time of release Step 2. Turn in to the Record Request Fiscal Officer Note: v If EMS Run Report is Requested, they need to Fill out the HIPPA Authorization Form v The only Forms of Identification to be accepted is Driver License or Ohio State ID card with Picture
PUBLIC RECORDS REQUEST FORM Jefferson Township, Montgomery County Ohio (JT) grants Jefferson Township citizens the right to access open public records that exist at the time of the request. Jefferson Township does not require records custodians to compile information or create or recreate records that do not exist. To: Fiscal Officer Jefferson Township, Montgomery County Ohio From (Name / Address & Telephone Number: [Insert Governmental Entity Name and Contact Information for the Public Records Request] [Insert Requestor s Name and Contact Information (include an address for any required written response)] Date of Request: Is the requestor a Jefferson Township resident? Yes No Request: Inspection (JT does not permit fees or require a written request for in office inspection only.) Copy/Duplicate - Cost $0.05 / per copy; plus, postage (if mailed) out of office $5.00per run minimum, $.05 per page above 100 pages Fire Reports $5.00 EMS Reports $5.00 Must Complete HIPPA Form and ID verified Driver License or State ID Card Delivery preference: On-Site Pick-Up USPS First-Class Mail Electronic Email Address: Other: Records Requested: Provide a detailed description of the record(s) requested, including: (1) type of record; (2) timeframe or dates for the records sought; and (3) subject matter or key words related to the records. The Jefferson Township record requests must be sufficiently detailed to enable a governmental entity to identify the specific records sought. As such, your record request must provide enough detail to enable the records custodian responding to the request to identify the specific records you are seeking. Please note: The office may contact you at the information given above within 7 business days for any questions or concerns. Use the back of the form. HIPPA Requirement: Requires an Authorization Form to request a emergency medical service EMS run report, due to HIPPA Laws, the requestor must complete both Public Records Form and HIPPA Authorization Form. Signature of Requestor Signature of Fiscal Officer Date Submitted Date Received USDA Nondiscrimination Statement Last Published: 10/01/2015 In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, religion, sex, gender identity (including gender expression), sexual orientation, disability, age, marital status, family/parental status, income derived from a public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (not all bases apply to all programs). Remedies and complaint filing deadlines vary by program or incident. To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at How to File a Program Discrimination Complaint and at any USDA office or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: (1) mail: U.S. Department of Agriculture, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email: program.intake@usda.gov. 1 P a g e Ed on 10.01-18
One Business Park Drive * Dayton, Ohio 45417-8403 * 937.262.3591 * Fax: 937.262.3599 *www.jeffersontwp.org PUBLIC RECORDS REQUEST FORM Records Requested: Provide a detailed description of the record(s) requested, including: (1) type of record; (2) timeframe or dates for the records sought; and (3) subject matter or key words related to the records. The Jefferson Township record requests must be sufficiently detailed to enable a governmental entity to identify the specific records sought. As such, your record request must provide enough detail to enable the records custodian responding to the request to identify the specific records you are seeking. Please note: The office may contact you at the information given above within 7 business days for any questions or concerns. Detailed Description: Signature: Date: 2 P a g e Ed on 10.01-18
JEFFERSON TOWNSHIP FIRE DEPARTMENT HIPAA AUTHORIZATION FORM For EMS Report Request Only Patient s Full Name Patient s Social Security Number/Medical Record Number Address Patient s Date of Birth City, State Zip Code Patient s Telephone Number ******Copy of Driver License or State ID Required ****** I hereby authorize use or disclosure of protected health information about me as described below. 1. The following specific person/class of person/facility is authorized to use or disclose information about me: 2. The following person (or class of persons) may receive disclosure of protected health information about me: His/Her/Its Name Address City, State Zip Code 3. The specific information that should be disclosed is (please give dates of service if possible) 4. UNLESS YOU SIGN HERE, NO INFORMATION ABOUT ALCOHOL/SUBSTANCE ABUSE, HIV/AIDS, OR MENTAL HEALTH WILL BE DISCLOSED: YES, DISCLOSE THIS INFORMATION * NO, DO NOT DISCLOSE THIS INFORMATION * 5. I understand that the information used or disclosed may be subject to re-disclosure by the person or class of persons or facility receiving it, and would then no longer be protected by federal privacy regulations. 6. I may revoke this authorization by notifying in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions. 7. My purpose/use of the information is for. 8. This authorization expires on,, OR upon occurrence of the following event that relates to me or to the purpose of the intended use or disclosure of information about me:. FEES FOR COPIES: Federal and state laws permit a fee to be charged for the copying of patient records. $5.00 Per EMS run call, then your copies will be mailed along with an invoice. THIS FORM MUST BE FULLY COMPLETED BEFORE SIGNING note that signature is required in two places. * Signature of Individual* (The person about whom the information relates) OR, if applicable Date of Individual s Signature Date of Birth or Social Security Number Signature of Guardian* or Date of Guardian s/personal Description of Authority to Act Personal Representative of Patient s Estate Representative s Signature for the Individual Page 1 ED 10.01.2018` A copy of this completed, signed and dated form must be given to the Individual or other signature. Official Use Only Received Processed By Log #
PUBLIC RECORDS REQUEST FLOW CHART Step 1. Provide Proper Records Request Form to the requestor Make sure it s filled out completely Make sure its signed Payment is due at time of release Step 2. Turn in to the Record Request Fiscal Officer Note: If EMS Run Report is Requested, they need to Fill out the HIPPA Authorization Form The only Forms of Identification to be accepted is Driver License or Ohio State ID card with Picture Page 2 ED 10.01.2018`