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Home
About Us
Charitable Sector
Capability Statement
Employee Spotlight
Executive Directors
Performance Management Reports
Strategic Plan
Services
Individual Therapy
Group Therapy
Medication Management
Targeted Case Management
Targeted Life Skills (TLS) Program
Care Coordination for Minors
Psychiatric Rehabilitation Program for Adults (PRP/A)
Psychiatric Rehabilitation Program for Minors (PRP/M)
Transportation
Submit A Referral
EMRC Referrals
BCDSS Wellness Program
Targeted Life Skills Program
Outreach and Events
Careers
Patient Payment Portal
Baltimore
Edgewood
Glen Burnie
Owing Mills
Temple Hills
Employee Portal
EMRC Training Request
ADP Employee Login
EAP Login
Relias Training
InSync Login
Internal Referral Form
Medical Records Request
Existing Client Collaboration
Medical Records Request Form
Patient Information
Full Name
*
Date of Birth
*
Street Address
*
City
*
State
*
ZIP
*
Phone
*
Email Address
*
Medical Provider
Provider/Facility Name
*
Street Address
*
Suite
City
*
State
*
ZIP
*
Phone
*
Fax Phone
Records Requested
Type of Records
*
(e.g., complete medical records, specific test results, visit notes, etc.)
Start Date Range
*
End Date Range
*
Purpose of Request
*
(e.g., personal use, transfer to another provider, legal purposes, etc.)
Authorization
I, the undersigned, acknowledge that client specified above has provided their consent for the release of their medical records. A copy of the signed Release of Information form is attached for your reference.
Name
*
Signature
*
Start signing your signature here
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Date
*
Release of Information
Please upload the signed Release of Information from here.
Upload file
*
Choose File
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Additional Instructions
*
Request Record
Please do not fill in this field.
