Attorney Representing the Parent 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. An authorization to release the record that:

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

B.)  Affirms the parent/child relationship.

C.)  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.

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

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

F.)  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...

3. A letter of request on your letterhead that includes the patient's name, incident date, incident time and incident location, and that affirms the pertinent information identified in ( 2.B.) and ( 2.C.), And...

4. A copy of the document by which the parent 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