Release of Medical Records from FCP

**IMPORTANT: If you are releasing records in order to transfer to another pediatrician, the patient(s) will be marked inactive in our system. Once records are sent, we will only be able to provide sick care, medical advice, or medication refills for up to 30 days. Thank you!
Authorization to Release Medical Records
Authorization to Release Medical Records
Patient Name #1*
Date of Birth*

MonthDayYear
Date
Patient Name #2
Date of Birth

MonthDayYear
Date
Patient Name #3
Date of Birth

MonthDayYear
Date
Patient Name #4
Date of Birth

MonthDayYear
Date
Patient Name #5
Date of Birth

MonthDayYear
Date
Patient Name or Parent/Guardian Name (if patient is under 18)*
Relationship to patient*
Patient's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone*
Reason for Release of Records*
Information to be disclosed

Medical RecordImmunization RecordOther
Records to be released to: (Name of Physician, Practice, Company, or Self)*

Name
Address of Physician, Practice or Company*** (We do not mail records; we will fax or email via HIPAA compliant email)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Fax Number (If you are a parent releasing records to yourself, please enter all zeros, and provide email below)*
Email
example@example.com
I hereby authorize Frederick County Pediatrics to release health information for the above named patient(s). This authorization is valid for 12 months from the date of signature. I understand that I may cancel this request with written notification, but that it will not affect any information released prior to notice of cancellation.
Signature of Patient or Parent/Guardian if patient is under 18** (If patient is over 18, the patient must sign the release for themselves)*

Clear
Date

MonthDayYear
Date
Should be Empty:

**IMPORTANT: If you are releasing records in order to transfer to another pediatrician, the patient(s) will be marked inactive in our system. Once records are sent, we will only be able to provide sick care, medical advice, or medication refills for up to 30 days. Thank you!

Authorization to Release Medical Records