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Attorney Representing the Parent of a Minor Child

Provide the Following

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

2. An authorization to release the record that:

  • Is in writing, dated, and signed by the parent
  • Affirms the parent/child relationship
  • Affirms that the parent's authority to consent to health care for the minor has not been specifically limited by a court order or a valid separation agreement entered into by the parents
  • Identifies the Baltimore County Fire Department as the health care provider
  • Identifies to whom the record is to be provided
  • States the time period for which the authorization will be valid, which may not exceed one year
  • Authorizations missing any of the required elements will not be accepted

A Second Option

You also may provide a letter of request on your letterhead that includes:

  • Patient's name, incident date, incident time and incident location
  • Affirms the parent/child relationship
  • Affirms that the parent's authority to consent to health care for the minor has not been specifically limited by a court order or a valid separation agreement entered into by the parents
  • Provide a copy of the document stating that the parent has appointed you to represent him or her

Regardless of which option you choose, send all required documentation with a check or money order in the amount of $10, payable to "Baltimore County Office of Finance":

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

Revised May 17, 2013

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