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

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 our Jet Wing location)

CD-Computer Disk (receive via Mail - unlimited pages)

Email Address (enter email address if you would like your records emailed to you) *

Your paper copies can be picked up at the following location:
Diversus Health
1795 Jet Wing Dr.
Colorado Springs, CO 80916

Mailing Address (please include City, State & Zip) *

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