EmailMeForm
Authorization for Release of Medical Records
Complete this form to request your medical records to be transferred to another party.
Name of Patient
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Patient Date of Birth
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MM
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DD
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YYYY
Which records would you like to release?
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RELEASE MOST RECENT PHYSICAL EXAM FINDINGS INCLUDING: medications, complete problem list, labs, pathology, EKG, PAP, and mammogram report. If a child, please include, immunization history.
Specific Records Only:
Release my Medical Records TO:
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Practice Name
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Phone Number
Fax Number
Email Address
I understand that my medical records are protected under State and Federal confidentiality regulations. Disclosure of information regarding drug and/or alcohol abuse and treatment, confirmed sexually transmitted infections, including testing and treatment for HIV/AIDS, and diagnosis of mental illness or psychiatric care cannot be released without my written consent.
All applicable records will be released if nothing is marked or noted.
Drug and/or alcohol abuse, diagnosis or treatment
HIV/AIDS testing and/or treatment
Psychiatric care and/or mental illness
Confirmed STD test results and/or treatment.
I understand that per the Colorado Medical Records Copying Charges Law I may be charged reasonable fees for records that are being released to the patient, law firms, or any third party that is not a medical provider. There is no charge to send records to another medical provider ensure continuity of care.
Patient/Legal Guardian Signature
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Clear