New Patient Record Release

Request for Medical Records to be sent to Frederick County Pediatrics

(OK to fill out 1 form per family / up to 5 children)
Patient #1 Name
#1 Gender
#1 Date of Birth

MonthDayYear
Date
Patient #2 Name
#2 Gender
#2 Date of Birth

MonthDayYear
Date
Patient #3 Name
#3 Gender
#3 Date of Birth

MonthDayYear
Date
Patient #4 Name
#4 Gender
#4 Date of Birth

MonthDayYear
Date
Patient #5 Name
#5 Gender
#5 Date of Birth

MonthDayYear
Date
Parent/Guardian Name
Relationship
Address
City, State, Zip
Phone
Format: (000) 000-0000.
Reason for Release of Records:

Other
Information to be disclosed:

Other
Name of Physician / Practice
Address
Address line 2
Phone Number
Format: (000) 000-0000.
Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
*Fax / electronic transfer preferred

Please include patient demographics
I hereby authorize Frederick County Pediatrics to obtain health information for the above named patient(s). This authorization is valid for 12 months from the date of signature. I understand that 1 may cancel this request with written notification but that it will not affect any information released prior to notification of cancellation.
Signature of Parent/Guardian
Date

MonthDayYear
Date
Should be Empty:

Request for Medical Records to be sent to Frederick County Pediatrics