2. Creating a Profile
   You do NOT need to create a profile in order to submit this form. If you do want to set up a profile in order to review your submitted form, you must create your profile BEFORE filling out the form and submitting it.
4. Are you the patient or legal representative who is requesting records to be sent to the patient?*

   A HIPAA compliant authorization to release medical information must be submitted for release of the patient's information to anyone other than the patient. See the link below to download the form before completing this form.

   1. Yes
   2. No
6. Download the HIPAA Release Form
   Authorization to Release Medical Information

   Please fill out this fillable PDF form that provides authorization to release the patient's information to someone other than the patient.
7. Upload HIPAA Release from Patient
9. Patient's First Name*
10. Patient's Last Name*
12. Address*
14. City*
15. State*
16. Zip Code*
18. Phone Number*
19. Email Address*
21. Patient's Birth Date*
22. Date of Incident/Service*
24. What records do you want?*
26. Preferred Method of Delivery*

    Please check your preferred method.

    1. Email (unsecured)

    1. Mail to Address Listed Above

    1. Fax (unsecured)

    1. Pick Up in Person (ID required)
28. Security Warning
    Records that are sent through unencrypted fax/email that are not secure, and there is a risk that the records could be seen by a third party during electronic transmission, while in electronic storage, and/or upon completed delivery. The District is not responsible for unauthorized access of the Protected Health Information resulting from the faxed or emailed transmission, or for safeguarding the Protected Health Information upon delivery.
30. Open Records Act Policy and Associated Fees
    All requests for public records shall be in writing and shall comply with the requirements of the Open Records Act, HIPAA, and any other applicable federal or state laws, rules, or regulations. In general, the District will respond to a request within three working days as required by C.R.S. § 24-72-203(3)(b); however, if the District finds extenuating circumstances exist, as described in C.R.S. § 24-72-203(3)(b), the District may take up to seven working days to respond. The response time begins the first working day following receipt of the request. A request received after 5 p.m. or on any day the District is officially closed will be considered received as of the following working day. Those who submit a records request may be required to pay fees for the requested records, depending on the length of time it takes to fulfill the request and the amounted of printed and copied material provided for the request. You can review our fees policy within the Open Records Act Policy posted on our website.
32. Printed Name of Legal Representative if Patient is Not Capable of Signing
    If this form is not signed by patient, identify relationship to patient. If legal representative or other, provide documentation establishing authority such as Power of Attorney.
34. Upload Power of Attorney (if signing for patient)
36. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
38. Electronic Signature of Patient or Legal Representative
39. Date*
    Date

    Date
Leave This Blank:


41. 1. Receive an email copy of this form.
42. Email address

    This field is not part of the form submission.

43. Submit

* indicates a required field