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(410) 929 -4793

 

 

Mental Health Records Request

According to Maryland State Law if your medical records relate to a psychiatric or a psychological problem, your provider  has the discretion to decide whether or not to release them with you. However, you are entitled to receive a written summary of the records if you make a written request. Even if you cannot obtain the records, the health care provider from whom you are requesting the records may allow another health care provider treating you for the same condition to see and copy them.

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How to Request a Copy of Your Medical Records

 

Step 1: Fill Out the Form

To request a copy of your medical records for yourself or to have your medical records sent to a third-party, download and complete the

 

1. Print the Authorization For Release of Mental Health 

2. Attach copy of your identification card. 

3. Send both documents by:

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Email:fccc1@hushmail.com or

Mail: 9199 Reisterstown Rd Suite 105B Owings Mills, MD 21117

Fax: 410 779 9400

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Please do not come to the office with the intention of picking up copies immediately.

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Private Physician or Facility Request

Records will be faxed to designated provider or facility.

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Personal Copy Request

After receipt of the release form, your provider will decide to either release records requested of provide a written summary of records

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Costs for Copies

In accordance with federal and state laws, processing fees and copying charges may apply:

• If the record is being released directly to your private physician or another health care facility, there is no charge associated with copying your records.

• Third-Party Requests: Third parties may be charged a flat fee for retrieval in addition to fees associated with producing these records.

• The costs may vary depending on the facility and are subject to change in accordance with the state and federal laws.

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How long does it take to receive my records?

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Records will be available within 15 business days. If your record is not available within 15 days, we will let you know, and your record will be ready within 21 days from your original request.

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Request Amendment to Medical Record:

Maryland law allows the parent or patient to request an amendment (addition or other correction) to the medical record at any time. The parent or patient can request an amendment by sending a letter or completing a form designed for this purpose. The letter or form must be attached to the report and indicate the disagreement. 

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Please note that NO information can be deleted from the medical record. If the medical professional who entered the original record finds the parent or patient's claim to be correct, he or she may add an "addendum" to the record, but may not delete the original information.

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Instructions:

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1. Print the Patient Amendment Request Form

2. Attach copy of your identification card. 

3. Send both documents by:

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Email:fccc1@hushmail.com or

In person or mail: 9199 Reisterstown Rd Suite 105B Owings Mills, MD 21117

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Revocation of Release Form 

The Privacy Rule gives individuals the right to revoke, at any time, an Authorization they have given. The revocation must be in writing, and is not effective until received by FCCC. 

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Instructions:

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1. Complete Revocation Form

2. Include copy of identification card.

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Email:fccc1@hushmail.com or

Mail: 9199 Reisterstown Rd Suite 105B Owings Mills, MD 21117

Fax: 410 779 9400