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.
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.
Please fill out this fillable PDF form that provides authorization to release the patient's information to someone other than the patient.
Please check your preferred method.
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.
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.
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.
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.
This field is not part of the form submission.
* indicates a required field