EmailMe Form - Authorization for Release of Medical Records

Name of Patient *

Patient Date of Birth *

MM / DD / YYYY

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: *

Practice Name

*

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 *

Clear