ADCOM Records Request

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 https://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 *

First

Last

Date of Request

Address

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Phone

Date and Time of Occurrence

Date

Time

Responding Agency

Locations of Occurrence

Type of event

Additional Information

Protected Health Information

If 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 me
By 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 paid
By mail to the following address
By fax to the following fax number
By email to the following email address

By mail to the following address:

Address Line 1

Address Line 2

City

State

Zip Code

By unsecured fax to the following fax number:

By unsecured email to the following email address: *

Signature

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 Date

Read the Policy Here

Privacy Policy Confirmation: *

I have read and accepted

Click the link below to provide payment via credit or debit card:

YTD Total

Protected Health Information

Criminal Justice Records:

Signature