Go To Search
PrintEmail PageRSS
EMS Reports and Privacy Statements
Requesting an EMS Report

You can request an Emergency Medical Services (EMS) report or health record by completing a Health Insurance Portability and Accountability Act (HIPAA) Privacy Authorization Form. Please note, receiving these records requires a notarized signature.
Please contact Fire Department Administration with questions via email or at 952-895-4570.


Burnsville Ambulance Privacy Statements


Self/Patient Signature Statements:

Authorization of Billing: I authorize the submission of a claim for payment to Medicare, Medicaid, or any other payer for any services provided to me by the Burnsville Fire Department now, in the past, or in the future, until such time as I revoke this authorization in writing. I understand that I am financially responsible for the services and supplies provided to me by the Burnsville Fire Department, regardless of my insurance coverage, and in some cases, may be responsible for an amount in addition to that which was paid by my insurance. I agree to immediately remit to the City of Burnsville any payments that I receive directly from insurance or any other source whatsoever for the services provided to me and I assign all rights to such payments to the City of Burnsville. I authorize the City of Burnsville to appeal payment denials or other adverse decisions on my behalf without further authorization. I authorize and direct any holder of medical, insurance, billing or other relevant information about me to release such information to the Burnsville Fire Department, the City of Burnsville and its billing agents, the Centers for Medicare and Medicaid Services, and/or any other payers or insurers, and their respective agents or contractors, as may be necessary to determine these or other benefits payable for any services provided to me by the Burnsville Fire Department, now, in the past, or in the future. I also authorize Burnsville Fire Department, the City of Burnsville and its billing agents to obtain medical, insurance, billing and other relevant information about me from any party, database or other source that maintains such information.

Parent / Guardian Signature Statement:

Authorization of Billing: I am signing on behalf of the patient to authorize the submission of a claim to Medicare, Medicaid, or any other payer for any services provided to the patient by Burnsville Fire Department now, or in the past, (or in the future, where permitted). By signing below, I acknowledge that I am one of the authorized signers listed below. My signature is an acceptance of responsibility for any services that are not paid/covered by insurance. A copy of this authorization shall be valid as the original and shall remain in effect until revoked in writing by the patient/insured. I request payment of medical insurance benefits either to me or to the ambulance service. Authorized representatives include only the following individuals: • Patient’s legal guardian• Relative or other person who receives social security or other governmental benefits on behalf of the patient • Relative or other person who arranges for the patient’s treatment or exercises other responsibility for the patient’s affairs• Representative of an agency or institution that did not furnish the services for which payment is claimed (i.e., ambulance services) but furnished other care, services, or assistance to the patient.

Waiver of Liability:

I refuse treatment and/or transportation by the providing ambulance service. I assume responsibility for my own, my child's own, or any family member's medical treatment. I have been advised to seek the attention of a physician. I release the providing ambulance service, its employees, officers and directors from liability resulting from my own, my child's own, or any other family member's refusal of medical treatment or transportation.

Help Center