Records Requests

Authorization to Release Medical Information

Authorize ADCOM to release records containing a patient's protected health information to a person or organization you choose.

Before You Start

How a release authorization works

1List the recordsBe as specific as you can: the type of record, the date or date range, the subject and the people or places involved.
2Name the recipientThe person or organization the records may go to, and whether we send them by mail, fax or email.
3Sign the authorizationThe patient, or their personal representative, signs by typing their name. The authorization lasts one year unless revoked in writing.

Is this the right form?

Use this form when records containing your protected health information should go to someone else, such as an attorney, insurer or doctor.

Want the records sent to yourself? Use the Patient Access Request form instead.

Questions? Call the Records line at 303-289-2235.

1Patient information

Patient's first name *

Patient's last name *

Patient date of birth

Patient address line 1

Address line 2

City

State

Zip code

Patient phone

Your email *

We send your confirmation to this email, with a copy of the signed authorization.

2Records to release

I, (print name) *

authorize the Adams County Communications Center (ADCOM) to release the following records, including any Protected Health Information regarding the patient that the records contain.

Records to release *

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. 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.

3Who receives the records

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

Recipient address line 1

Address line 2

City

State

Zip code

For the purpose of

4How we send the records

Records are sent by U.S. mail or delivery service unless you authorize electronic transmission. *

By U.S. mail or delivery service to the recipient's address above. By fax. I authorize transmission via electronic means.

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.

Recipient's fax number *

By email. I authorize transmission via electronic means.

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.

Recipient's email address *

5Terms and signature

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.

Who is signing? *

I am the patient. I am the patient's personal representative.

Description of personal representative's authority *

Signature of patient or personal representative, type your full name *

Date *

Submitting sends your authorization to our Records staff. You will also get an email confirming it, with a copy attached.