Release of Information

To Request a Patient’s Health Information: Please complete the Authorization form to release information. 

1. Please fill in the Patient’s Name and Date of Birth Record the name of the person, facility, physician, etc who is to receive the information. 

2. Include their address and phone# or fax# if applicable. 

3. Include the name/phone # of someone we can contact if the information is going to someone other than the patient or their legal guardian. 

4. Check off the information that is needed. ***Note: the complete medical record is rarely needed for continuation of treatment with another physician. Generally all they need are the admission, discharge, any consultation reports, labs & s-ray reports, meds, and evaluations. If anything more is needed you or the physician can contact us. 

5. Federal Laws regulate the release of behavioral health (psychology and psychiatry) information. A psychologist or psychiatrist has the option to release a summary of the patient’s treatment instead of all the individual notes. Please specify if you are requesting evaluations, testing results, or progress notes. 

6. We need to have a “signature” of the legal guardian or the patient (if 18 or over). 

7. If the legal guardian is the parent and the patient is under 18, please sign the request. If the legal guardian is someone other than the parent or patient, we need proof of their authority to act in the patient’s behalf unless this information was given to us earlier and is in the patient’s chart. 

8. Return the signed authorization to the hospital. You may a. drop it off at inpatient or outpatient medical records department or b. fax it to 410-578-0567 or c. scan it and email it to: ____________________________ or d. mail it to the address below: Mt. Washington Pediatric Hospital Attention: Health Information Management Department, 3rd floor 1708 West Rogers Avenue, Baltimore, Maryland 21209 

9. Please note that there may be a charge for copying this information. If there is a charge, our department will contact you with the cost. 

10. If you have any questions please contact the HIM department at 410-578-2657 between the hours of 8:30 am and 4:30 pm.