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Adcom911

Consolidated Police, Fire and EMS Dispatch Center

Records Request

To request a copy of a 911 recording or associated transcript please complete the following:

* Review the ADCOM Open Records Request Policy

To request the report or transcript by fax, mail or in person please complete this form and print.

* Complete the ADCOM Open Records Request Form by CLICKING HERE.

* Either return the completed form in person to:

7321 Birch Street, Commerce City, CO 80022 8:00a.m.-5:00p.m., Monday – Friday.  OR 

Fax the form to 303-287-2942 OR

To request online see forms below and complete the ADAMS COUNTY COMMUNICATIONS CENTER (ADCOM) RECORDS REQUEST FORM along with any other applicable forms as needed mentioned in the request below. 

When the report is complete, you will be notified by the method you have indicated on the ADCOM Open Records Request Form.

A deposit of $7.50 is required with the request. If additional costs are incurred, notification will be made and payment is due prior to the report being picked up, faxed or emailed. If a report is not available the deposit will be refunded.

Acceptable forms of payment are: checks (with ID) and exact change (cash for making change is not kept on premises).  Credit Cards are accepted. Please contact 303-289-2235 for additional information.

If you complete the online records request, you will be contacted for payment of the deposit.

Payment may be mailed or accepted in person at: 7321 Birch Street, Commerce City, CO  80022


 

ADAMS COUNTY COMMUNICATIONS CENTER AUTHORITY (ADCOM) RECORDS REQUEST FORM

NOTICE: A copy of ADCOM's Policy Regarding Requests for Public and Criminal Justice Records ("Policy") may be obtained from ADCOM's administrative offices at 7321 Birch St., Commerce City, CO 80022, or on its website at http://www.adcom911.org/. All records requests must comply with the Policy; the Colorado Public (Open) Records Act, C.R.S. § 24-72-201, et seq.; the Colorado Criminal Justice Records Act, C.R.S. § 24-72-301, et seq.; the Health Insurance Portability and Accountability Act of 1996, the 2009 Health Information Technology for Economic and Clinical Health Act, and their implementing regulations and applicable Court decisions (collectively, “HIPAA”); and all other applicable law. ADCOM will charge fees for its responses to a records request as provided in the Policy.

Person Requesting Records

Records Requested

Please list below the records you are requesting with as much specificity as possible, including the type of record, a date or date range, the specific subject matter, and the names of persons or locations.

Protected Health Information

Criminal Justice Records

If any of the records you are requesting constitute Criminal Justice Records pursuant to the Colorado Criminal Justice Records Act, you must submit a Statement Affirming No Pecuniary Gain form below.

SIGNATURE

I certify that I am the person requesting the records identified above. I agree to pay all fees and costs incurred in responding to this request pursuant to ADCOM's Policy Regarding Requests for Public and Criminal Justice Records before the records are released to me.

SIGNATURE: I understand that authorization for the disclosure of these records and Protected Health Information is voluntary and I can refuse to sign this authorization. I understand that medical treatment, payment, enrollment, and eligibility for benefits cannot be, and are not, conditioned on whether I sign this authorization. Photocopies of this authorization may be used in lieu of the original. By typing your name below you signify your typed signature is to the same extent as if you had signed this document in ink.Your heading

Patient Access Request for Protected Health Information

NOTE: This form is only for a patient/Legal Representative to request medical records be sent to the patient. A HIPAA compliant Authorization to Release Medical Information must be submitted for release of patient’s information to anyone other than the patient.

Patient Information

* Warning: Records will be sent through unencrypted fax/email that is 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. ADCOM 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. By signing this form, you understand the risks and authorize this method of transmission.

SIGNATURE: I understand that authorization for the disclosure of these records and Protected Health Information is voluntary and I can refuse to sign this authorization. I understand that medical treatment, payment, enrollment, and eligibility for benefits cannot be, and are not, conditioned on whether I sign this authorization. Photocopies of this authorization may be used in lieu of the original. By typing your name below you signify your typed signature is to the same extent as if you had signed this document in ink.

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.

AUTHORIZATION TO RELEASE MEDICAL INFORMATION

Please list the records you are authorizing for release with as much specificity as possible, including the type of record, date or date range, the specific subject matter, and the names of persons or locations. Please attach additional pages if more space is needed. You must specifically authorize the release of records relating to drug/alcohol abuse, child abuse, HIV status, genetic testing, sickle cell anemia, or mental health records. A separate authorization is required for release of psychotherapy notes.

The records listed above may be released to the following individual(s) or organization(s):

OPTIONAL Authorization to Transmit via Electronic Means: I request that the records listed above be released to the recipient by fax or email, and not by U.S. mail or delivery service. I understand the records will be sent through unencrypted fax/email that is 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. ADCOM 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.

EXPIRATION. Unless earlier revoked, this authorization will expire, without my express revocation, one year from the date of signing, or if I am a minor, on the date I become an adult according to state law. REVOCATION. I have the right to revoke this authorization in writing at any time, except to the extent that action has been taken based on this authorization. PATIENT RIGHTS. I understand I have a right to a copy of this authorization. I have the right to inspect or copy the information to be disclosed as provided in 45 CFR 164.524. I have the right to inspect or amend my medical records as provided in 45 CFR 164.526. I have a right to an accounting of the use and disclosure of my health information to any third party as provided in 45 CFR 164.528. RE-DISCLOSURE. I understand that any disclosure of Protected Health Information carries with it the potential for unauthorized re-disclosure, and may no longer be protected by federal confidentiality rules.

SIGNATURE: I understand that authorization for the disclosure of these records and Protected Health Information is voluntary and I can refuse to sign this authorization. I understand that medical treatment, payment, enrollment, and eligibility for benefits cannot be, and are not, conditioned on whether I sign this authorization. Photocopies of this authorization may be used in lieu of the original. By typing your name below you signify your typed signature is to the same extent as if you had signed this document in ink.

STATEMENT AFFIRMING NO PECUNIARY GAIN

By typing your name below you signify your typed signature is to the same extent as if you had signed this document in ink.