Authorization for Release of Medical Records
Complete this form to request your medical records to be transferred to another party.
Name of Patient
Patient Date of Birth
Which records would you like to release?
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:
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