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 authorized to consent to health care, And...
3. An authorization to release the record that:
A.) Is in writing, dated, and signed by the authorized person
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.) Describes the reason the record is being requested
F.) States the time period for which authorization will be valid, which may not exceed one year
Note: Authorizations missing any of the required elements will not be accepted.
Or...
4. A letter of request from you that includes the patient's name, incident date, incident time, and incident location, the reason the record is being requested, And...
A.) A copy of the document by which the person authorized to consent to health care has appointed you to represent him or her
B.) A copy of the document by which the person is authorized to consent to health care
Note: A Reason for the Request is required in accordance with Maryland Public General code; Health-General, TITLE 4, Statistics and Records, SUBTITLE 3, Confidentiality of Medical Records: A? 4-301 (k) (2) states that a person authorized to consent to health care for an adult who requests a copy of a medical record is a person in interest when "consistent with the authority granted".
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 April 8, 2004
Courthouse 