Request a Patient Care Report

  1. Medical Records Information

    Request a Patient Care Report

    Citizens have the right to request a copy of their Patient Care Report (PCR) at any time. If you would like a copy of your PCR, please fill out the form below. In order to obtain a form for someone other than yourself, you must show proof of Power of Attorney, Medical Proxy, or Executor of the Estate paperwork. Reports cannot be emailed and must be picked up in person at Public Safety, located at 315 Stafford Road, Prince Frederick, MD 20678. An government issued ID will be required.

    If you are requesting a PCR through a law firm or any other outside agency, please fax the subpoena and/or HIPAA Release Form or the official request on letterhead with the following information to 443-486-4074, Attn. Heather Howes:

    1. Patient Name and DOB
    2. Date of Incident
    3. Location and type of Incident
    4. Records being requested
  2. Patient Information:
  3. Information released to:
  4. Information requested:
  5. Purpose or need for the information requested:*
  6. Consent to disclose information*

    I understand this consent is voluntary and that I may revoke this authorization at any time (except to the extent that action based on this consent has already been taken) by written, dated and signed communication. This consent will remain in effect no more than ninety (90) days from the date I signed this consent. I also understand that my medical records may include mental health information, drug/alcohol information and/or HIV information.

    When my information is used or disclosed pursuant to this authorization, it may be subject to re-disclosure by the recipient and may no longer be protected by the federal HIPAA Privacy Rule.

    I understand I may refuse to sign this authorization. If I refuse, the identified records will not be disclosed. Whether I sign or refuse to sign, my treatment will not be affected.

  7. Consent to use of Electronic Signature*
  8. Leave This Blank:

  9. This field is not part of the form submission.