Patient Request To Access Medical Records Form
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1Patient Label
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Patient Request to Access Medical Records Form
#CHCR-001 rev. 08/11
Patient Request to Access
Medical Records Form
AUTHPHI
Littleton Adventist Hospital 7700 S. Broadway Littleton,CO 80122 P:303-730-5812 F:303-798-9824
Name of Facility/Entity: ____________________________________________________________________________________________________
Patient’s Full Name
E-mail Address:
Street Address:
City:
State:
Zip Code:
Phone #:
Date of Birth:
Last 4 of Social Security #:
Driver’s License/State-Issued ID #:
I’m requesting access to (please check one):
View Records Only
Obtain Copies of Records
Please complete the following information:
Date(s) of service associated with
request (e.g. date of treatment,
date of office visit):
If requesting copies, please
Further Medical Care
Worker’s Comp
Personal Use
Insurance
Legal
describe the reason for the request:
Other:__________________________________________________________________________________
Describe the information you are
D/C Summary
Labs
Radiology
H&P/Consult
ER Records
Operative Report
requesting to view or obtain copies
Medications
Progress Notes/Phys Orders
Specific Studies
Psych Health
of:
Entire Medical Record
Other: ____________________________________________________________________________________________
I certify that this request to access health information is made voluntarily and that the information given above is accurate to the best of my
knowledge. I understand that Centura Health may not be able to grant me access to certain types of health information and information
belonging to minors between the ages of 13-17 will not be accessible to ensure compliance with legal requirements regarding access to patient
records. I understand that if I need to obtain hard copies there may be a charge associated with such copies.
Signature of Patient/Legal Representative: __________________________________________ Date: ____________________ Time: ____________________
If Legal Representative, Print Name: ___________________________________________________ Relationship to Patient: _____________________________
Centura Health Use Only: Individual Who Received Request: ______________________________ Date Request Received: _____________________
Verification of Identity (driver’s license or other ID): _________________________________________________________________________________________
Medical Record #: _______________________________
Date Approved/Denied: ___________________________
Request Approved
Request Denied
Date Fulfilled (copies delivered/inspection complete): _______________________ Individual Who Fulfilled: ______________________________________
Patient Acknowledgement of Inspection (viewing only). __________________________________________________ Date: ____________________________
Reason for Denial (if applicable): ___________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________
PSYCHIATRIC RECORD PHYSICIAN APPROVAL: I am the attending physician for the above named patient. I have reviewed the medical
record(s) to determine if they contain information relative to psychological or psychiatric problems which, if revealed to the patient is
reasonably likely to endanger the life or physical safety of the individual or another person.
These portions of medical record(s):
May be released to the patient
May NOT be released to the patient
Signature of Physician or Designee: ___________________________________________________ Date: ____________________ Time: ___________________
Print Name of Physician: _______________________________________________________________
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Parent category: Legal