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.
Agency or individual Requesting Records
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

0/300 characters
Method you would like to receive *
Signature *