Attorney Representing a Duly Appointed Personal Representative

Please provide the following:

1. A letter of request on your letterhead that includes the patient's name, incident date, incident time and incident location, And..

2. A copy of the document by which the person is the duly appointed personal representative; And...

3. A copy of the Death Certificate; And..

4. An authorization to release the record that:

A.) Is in writing, dated, and signed by the personal representative

B.) Identifies the Baltimore County Fire Department as the health care provider

C.) Identifies the patient

D.) Identifies to whom the record is to be provided

E.) States the time period for which the authorization will be valid, which may not exceed one year

Note: Authorizations missing any of the required elements will not be accepted.

Or...

5. A letter of request from you that includes the patient's name, incident date, incident time and incident location, And...

A.)  A copy of the document by which the duly appointed personal representative has appointed you to represent him or her

B.)  A copy of the document by which the person is the duly appointed personal representative

C.)  A copy of the Death Certificate

Send all of  the required documentation with a check or money order in the amount of $10, payable to "Baltimore County Office of Finance" :

Records Department
Baltimore County Fire Department
700 East Joppa Road
Towson, MD 21286-5500

Revised July 13, 2009