Records Requests

Patient Access Request

Request your own protected health information from ADCOM, or a patient's, as their legal representative.

Before You Start

How a patient access request works

1Complete the form belowTell us who the patient is, which records you want and how you want them delivered, then sign.
2We review your requestOur Records staff will contact you if anything else is needed, including any fees for mail or pickup.
3Receive your recordsBy mail, in person with a government-issued photo ID, or by unsecured email or fax.

Is this the right form?

Use this form for records containing your own protected health information, or a patient's you legally represent. If your ADCOM Records Request involves your health information, this form goes with it.

Want records sent to a third party? Use the Authorization to Release Medical Information form instead.

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

1Patient information

Patient's first name *

Patient's last name *

Birthdate

Address line 1

Address line 2

City

State

Zip code

Phone

Email *

Date of incident/service

2Records requested

What records do you want? *

3Delivery method

How would you like your records delivered? *

Mail the paper information to my home address listed above (fees apply). I will pick up the records in person at ADCOM's administrative offices, 7321 Birch St., Commerce City, CO 80022. Government-issued photo ID will be required (fees apply). Unsecured email

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.

Email address for delivery *

Unsecured fax

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.

Fax number *

4Authorization and 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 legal representative (the patient is not capable of signing).

If this form is not signed by the patient, identify your relationship to the patient. If Legal Representative or other, provide documentation establishing authority, such as Power of Attorney.

Relationship to the patient *

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

Signature date *

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