Records Request FormPlease enable JavaScript in your browser to complete this form.Full Name *FirstLastDate of RequestAddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmail *PhoneDate and Time of OccurrenceDateTimeResponding AgencyLocations of OccurrenceType of eventAdditional InformationProtected Health InformationIf any of the above-records you are requesting contain health information protected from disclosure under HIPAA, you must check one of the following boxes and complete the additional form indicated: (Choose from the drop-down menu.)The records contain my protected health information, or I am the personal representative of the individual to whom the protected health information relates. You must submit the Patient Access Request for Protected Health Information form below.I am directing that records containing my protected health information be sent to a third-party. You must submit an Authorization to Release Medical Information form below. If you use your own form it must contain all required information and authorizations, or it will be rejected.Criminal Justice RecordsIf 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.I wish to inspect the records at ADCOM's administrative offices at 7321 Birch St., Commerce City, CO 80022, and do not want any copies of the records delivered to meBy pick-up at ADCOM's administrative offices at 7321 Birch St., Commerce City, CO 80022. Records not picked-up within 30 will be destroyed, without refund of any fees paidBy mail to the following addressBy fax to the following fax numberBy email to the following email addressCriminal Justice Records Mail to AddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeCriminal Justice Records Fax to AddressCriminal Justice Records Email to Address *SignatureSIGNATURE: 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. *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 DateRead the Policy HerePrivacy Policy Confirmation:I have read and acceptedClick the link below to provide payment via credit or debit card:Submit
