Records Request

McHenry Township Fire Protection District
3610 W Elm Street
McHenry, IL 60050
Phone: (815) 385-0075

INSTRUCTIONS

To request records, complete this form and submit to McHenry Township Fire Protection District.

If you prefer to submit a Printable Request, please download the file in the supporting documents section.

Requestor – Please read and submit the required item(s) below:

If you are the requester/patient, a proper form of identification (drivers license, state ID, etc.).
Proof of parental status or guardianship, if the patient is a minor. Acceptable proof is a copy of the patient’s birth certificate or a court document showing custody/guardianship.
Proof that a court has appointed you power of attorney or administrator of the patient, if the patient is deceased or has special needs.

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Requester Name

Patient Name

if different from Requester

Date of Birth

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Address

City, State ZIP

Item Requested

Incident Report

Billing Record

Additional Information Needed

Please be specific, include approximate date range, record type, etc.

Relationship

What is the requester's relationship to the patient (check only one)?

Self/Patient

Parent/Guardian

Executor/Power of Attorney

Other

Is the patient a minor?

Yes

Minor Patient Date of Birth

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File Upload

Upload required identification documentation here.
Files must be less than 5 MB.
Allowed file types: gif jpg jpeg png pdf doc docx.