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PHI Form (Client Access to PHI)
If you have questions or require assistance completing the form below,
please call our Medical Records department at 719-572-6100, option 4.
Date of Request
*
+
Phone
*
Client First Name
*
Client Last Name
*
Client Date of Birth
*
Is client 12-17 years old?
*
Yes
No
Choose One
*
I am the client
I am the parent of the client and the client is under 18 years old and not emancipated
I am a legally authorized representative of the client. (Legal representative MUST provide documentation of their right to represent the client)
I am requesting
*
Diversus Health Clinical Record
Diversus Health Clinical and Billing Record
Choose Method
Please note:
If you choose paper, records over 200 pages will be put on CD and mailed to the address provided
*
Email (receive via encrypted email - unlimited pages)
Paper (pick up at one of our locations)
CD-Computer Disk (receive via Mail - unlimited pages)