Medical Record Release Authorization Form - 2025 Logo
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  • Medical Record Release Authorization

  • The following information is required by law before we can release the medical records of your child. (See MD. Ann. Code, Health General, Title 4, Subtitle 3.)

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  • INCOMING TO GATEWAY PEDIATRICS

  • OUTGOING FROM GATEWAY PEDIATRICS

  • There may be fees associated with sending medical records from Gateway Pediatrics to another entity as allowed by Maryland Law. Our fee schedule is as follows:

    • Release to Parent/Patient/Patient Representative
      • No Charge for Electronic Format (if record is small enough to email)
      • $0.76/page for Printed Records

    • Release to Other Office (PCP/Specialist)
      • $10.00 fee per child (sent on CD via USPS)

    • Release to Other Party (Attorney, Insurance Company, Disability Review, etc.)
      • Requesting entity will be billed $22.88 + $0.76 per page if printed or $0.57 per page if sent electronically) + postage/shipping if mailed 

  • REASON FOR REQUEST:

  • INFORMATION TO BE RELEASED:

  • RECORDS WILL INCLUDE HIV-RELATED INFORMATION, HEALTH, DRUG/ALCOHOL ABUSE, AND MENTAL HEALTH ISSUES UNLESS SPECIFIED OTHERWISE IN THE SPACE BELOW. NOTE: PSYCHOTHERAPY NOTES ARE NEVER INCLUDED.

  • Per Maryland State guidelines, Gateway Pediatrics, LLC has 21 business days to release your medical records.

    I authorize the release of copies of medical records and/or other information as noted above. I authorize this information be released by the method selected
    above. If I have requested records be sent unencrypted, I understand and acknowledge the risk of sending PHI in an unsecured manner.

    I understand that I may revoke this authorization at any time to the extent that the person who is to make the disclosure has already acted in reliance on this authorization. If not revoked earlier, this consent will remain in effect for one year from the date signed. I understand I have a right to receive a copy of this request.

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