Request For Outside Medical Records
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1Request For Outside Medical Records
Patient’s Complete Name: Last: ________________ First: ________________ Middle: ________________
Last 4 digits of Social Security Number: xxx – xx - __________
Date of Birth _______/_______/_______
INFORMATION TO BE RELEASED FROM:
INFORMATION TO BE RELEASED TO:
International Center for Colorectal Care
___________________________________________ Children’s Hospital Colorado
(CHCO)
Organization
Organization / Person
th
13123 E. 16
Ave.
Aurora, CO 80045
__________________________________________________
B323
Street Address
City, State, Zip
Street Address
Box
City, State, Zip
720-777-9880
720-777-7891
__________________________________________________
Phone
Fax
Phone
Fax
INFORMATION TO BE RELEASED
x
x
FAX
PAPER
CD
OTHER
Format for records (please check ONLY one box):
Dates of service for records requested: Beginning __________________________ Thru________________________________
x
x
Complete Medical Record
Immunization Records
Operative Reports
Pertinent Information
x
x
Clinical Information/Notes
Lab Report
Emergency Room/Urgent Care
(Discharge Summary, H&P, X-
x
x
x
Discharge Summary
Pathology Report
Imaging Results
Ray, Lab, Operative, Consults)
x
all images
Other (please specify)__________________________________________
on disc
PURPOSE OF RELEASE
Continuation of Care
Other__________________________________________________________________________
AUTHORIZATION FOR GENERAL RELEASE OF INFORMATION
I understand that:
(1) My signature on this form is strictly voluntary. (2) I may revoke this authorization at any time in writing, and if I do, it will not have any
effect on any actions taken prior to receiving the revocation. Further details may be found in the Notice of Privacy Practices. (3) If the
requester or receiver is not a health plan or healthcare provider, the released information may be disclosed by the recipient and may no
longer be protected by federal privacy regulations. (4) If I do not sign this form, my healthcare, the payment for my healthcare or my ability
to enroll for benefits will not be affected. (5) I may inspect or obtain a copy of the health information that I am being asked to disclose.
Expiration: Without my express revocation, this consent will automatically expire upon satisfaction of the need for disclosure, but in
any event will expire 180 days from the date hereof, unless otherwise specified _________________.
Sensitive Records may require specific patient authorization. Please check the applicable box below to request the following
records:
Mental Health Treatment
Sexually Transmitted Diseases
AIDS/HIV Related
Alcohol/Drug Abuse Treatment
Psychotherapy Notes
Sickle Cell Anemia
Genetic Testing
This form must be filled out completely in order to obtain medical records
SIGNATURE OF PATIENT / LEGAL REPRESENTATIVE
Signature of Patient or Legal Representative
Date (month/day/year)
Relationship to patient, if not signed by patient
Patient Sticker
801501 Request for Outside Medical Records
(7/2013)
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Parent category: Medical