2. 
4. Name of person filing complaint:
6. First Name
7. Last Name
9. Address1
11. City
12. State
    -- Select One --ALAKAZCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNUTVTVAWAWVWIWYDC
13. Zip
15. Phone Number*
    Ex. 123-456-7890
16. Today's Date
    Today's Date
18. Address of Incident*
20. Date / Approx. Time of Incident
    Date / Approx. Time of Incident

    Date / Approx. Time of Incident
21. Was the complaint in relation to (check the one that applies)?

    1. Medical Call
    2. Fire Call
23. If medical call, please give the name of the patient(s) if different from the name of the person filing the complaint:
25. Please provide details of the incident (please be as thorough as possible):
27. HIPPA NOTICE
    The Shreveport Fire Department - Emergency Mecial Services (EMS) is required by the Health Insurance Portability and Accountability Act of 1996 (HIPPA) and Subtitle D of the Health Information and Technology for Economic and Clinical Health Act (HITECH) to protect the privacy of certain confidential health care information, known as Protected Health Information (PHI), and to provide you with a notice of our legal duties and privacy practices with respect to your PHI. This statement is being provided to inform you that it may be necessary to review PHI associated with you or a family member in order to adequately address this complaint. By selected the submit button, you acknowledge that you have read and agree to the contents of this HIPPA Notice
Leave This Blank:


29. 1. Receive an email copy of this form.
30. Email address

    This field is not part of the form submission.

31. Submit

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