Records Request FormPlease enable JavaScript in your browser to complete this 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.To request a copy of a 911 recording or associated transcript please complete the following: Review the ADCOM Open Records Request Policy Complete and submit the ADCOM Records Request Form Submit a deposit of $7.50 with request Select 'Make Payment' at the bottom of the page to pay by credit/debit card Other acceptable forms of payment are: checks (with ID) and exact change (cash for making change is not kept on premises) If additional costs are incurred, notification will be made and payment is due prior to the report being picked up, faxed or emailed. Refunds for deposits collected for a report not available or not within ADCOM911 jurisdiction will be considered on a case-by-case basis Please contact 303-289-2235 with any questions or for additional information. 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: 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 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.Delivery Method of Copies of Records: 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 days 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 addressBy mail to the following address:Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeBy unsecured fax to the following fax number:By unsecured email to the following email address: *SignatureSIGNATURE: *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
