Frederick, MD 21701 240-566-3300 DOB FREDERICK HEALTH HOSPITAL SEX FHH CareTrack Patient Portal Proxy Access Request and Authorization Form MR.PORTALPROXY FMH.47a (12/17/2018) Patient Name: _____ DOB: _____ MR#: _____ Or Patient Label Patient's Authorization By signing this proxy request, I understand that I am authorizing FHH to disclose ....