New Patient Record Release

Request for Medical Records to be sent to Frederick County Pediatrics
Patient #1 Name *
#1 Gender *
#1 Date of Birth *

Month Day Year
Date
Patient #2 Name
#2 Gender
#2 Date of Birth

Month Day Year
Date
Patient #3 Name
#3 Gender
#3 Date of Birth

Month Day Year
Date
Patient #4 Name
#4 Gender
#4 Date of Birth

Month Day Year
Date
Patient #5 Name
#5 Gender
#5 Date of Birth

Month Day Year
Date
Parent/Guardian Name *
Relationship *
Address *
City, State, Zip *
Phone *
Reason for Release of Records:
Reason for Release of Records:
Name of Physician / Practice *
Address
Address line 2
Phone Number *
Fax Number *
Please enter a valid phone number.
Frederick County Pediatrics 11717 Old National Pike, Suite 8 New Market, MD 21774

Phone: 301.882.7489 Fax: 301.882.7520
*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 *

Clear
Date *

Month Day Year
Date
Should be Empty:

Request for Medical Records to be sent to Frederick County Pediatrics