Request for Medical Records

This is NOT an authorization to release records.

An authorization/release of information must be on file or provided when requesting records.

If you are unsure if authorization/release of information is on file, please give medical records a call at 719-572-6100, Option 4.

Date of Request * +

Client Date of Birth *

Client First Name *

Client Last Name *

Agency or individual Requesting Records

Individual or Agency Name *

Phone *

Fax

Mailing Address (address, city, state, zip) *

Email Address

Information being requested

Information being requested (check all that apply) *

DUI ONLY - information that can be obtained/disclosed under this authorization includes the following:

Date range of records being requested

Start Date * +

End date * +

Upload Authorization/Release of Information

Purpose of your request *

0/300 characters

Method you would like to receive *

Secure Email

Fax

Mail (will receive records on CD)

Signature *

clear

Enrollment	Attendance, hours and weeks completed	Education/treatment levels	Compliance and ancillary services
Cooperation	Treatment status and progress	Fee payment	Discharge status