Reason for Release of Records:
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.