Attorney Representing a Court-Appointed Guardian or Custodian of a Minor Child

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 court order appointing the person as the guardian, custodian, or representative of the minor, And...

3. A written authorization to release the record that:

A.) Is signed and dated by the guardian, custodian, court appointed representative.

B.) Identifies the health care provider.

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

D.) 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 on your letterhead that includes the patient's name, incident date, incident time and incident location, And...

6. A copy of the court order appointing the person as the guardian, custodian, or representative of the minor, And...

7. A copy of the document by which the person has appointed you to represent him or her. 

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