City of Page | Information Request Form

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Date: *

Information Request Form

Thank you for your interest in Page City Government. A written request assists us in providing a complete and accurate response. Your request will be handled as soon as possible depending on sources and complexity of the information needed. Fees charged are set forth in Resolution No. 1100-12 (Exhibit "A" attatched.) You will be contacted for payment contigent upon results of your request. Health information requests for someone other than yourself must include a patient signed HIPAA form.

Requesting Party *

Mailing Address: *

City: *

State: *

Zip: *

Phone: *

FAX Number:

Email Address: *

List specifically the documents or information desired: *

Reason for information request: *

General information or research purposes

Commercial purposes*

*Please note, certain legal restrictions exist on the commercial use of governmental information.

Explain commercial use intended

HIPAA Form (if applicable)

Please confirm your signature by typing your full name in the box below.

I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature.

Enter text below. *