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KATHY M. SHEEHAN MAYOR CITY OF ALBANY DEPARTMENT OF FIRE, EMERGENCY & BUILDING SERVICES 26 BROAD STREET ALBANY, NEW YORK 12202 TELEPHONE (518) 447-7879 FAX (518) 447-7883 WARREN W. ABRIEL, JR. ACTING FIRE CHIEF AFD – Revised 01/2014 Authorization to Release Patient Care Reports from the City of Albany Department of Fire & Emergency Services In regards to the accident, injury or illness that occurred on or about at the following location I, (print name) hereby authorize the City of Albany Department of Fire & Emergency Services to release the Patient Care Report with any and all information which may be requested regarding my past and/or present physical condition and any and all treatment modalities rendered in the pre-hospital environment. I further authorize the City of Albany Department of Fire & Emergency Services to provide an official copy of the aforementioned record to (print name). Signature Date State of New York County of On this, the________day of before me a notary public, the undersigned officer, personally known to me (or satisfactorily proven) to be the person whose name is subscribed to the within instrument, and acknowledged that he executed the same for the purposes therein contained. In witness hereof, I hereunto set my hand and official seal. Notary Public