Authorization To Release And Or Obtain Patient Information
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1University of Colorado Hospital
Medical Record #
12401 E. 17th Avenue - Box A025
Patient Name(s)
Aurora, CO 80045
(720) 848-1031 Phone
(720) 848-5551 Fax
Date of Birth
UCH Psychiatric Services
Social Security #
(720) 848-6190 Phone
(720) 848-5549 Fax
Contact Phone #
AUTHORIZATION TO RELEASE AND/OR OBTAIN PATIENT INFORMATION
OBTAIN FROM: (Releasing facility)
RELEASE TO: (Receiving entity)
Name
Name
Address
Address
City
State
Zip
City
State
Zip
Phone
Fax
Phone
Fax
INFORMATION TO BE REVIEWED
:
IN ELECTRONIC MEDICAL RECORD ONLY
DURING PATIENT ADMISSION/VISIT IN HEALTH INFORMATION DEPARTMENT
INFORMATION TO BE PHOTOCOPIED AND RELEASED
(CHECK ALL THAT APPLY):
Date of service range (month/year): From:
To:
Emergency Room Report
Mental Health Treatment
Genetic Information
Discharge Summary
Drug/Alcohol Treatment
HIV/AIDS Information
Operative Report
Radiology Reports
Radiology Images
History and Physical
Laboratory Reports
Other:
Clinic/Progress Notes
_____ Immunization Records
THE PURPOSE FOR THIS RELEASE:
______Continuity of Medical Care
______Damage/Claim Information
______Personal Use
______Legal
Other:
AUTHORIZATION: I hereby give the releasing facility permission to disclose my individually identifiable health information
as listed above. I understand that once this information is disclosed, it may no longer be protected. I understand that this
authorization is voluntary, that further treatment can not be conditioned upon my signing this authorization. I acknowledge that
incomplete forms can not be processed and THAT THERE MAY BE A COST TO COPY THE RECORDS.
I understand that this consent expires 180 days from the date of my signature unless otherwise specified as follows:
______________________ I understand that I can take back permission to release my medical records at any time, except to the
extent that action has already been taken to comply with it. I understand that I must provide notice in writing if I choose to
revoke this authorization before the date/event of expiration, and that the written revocation must be signed and dated with a date
that is later than the date on this authorization. A copy, fax or scan of this form is to be considered as valid as the original.
Signature of Patient or Authorized Representative
Date of Signature
Printed Name
Relationship to Patient (if applicable)
ACKNOWLEDGEMENT OF ACCESS TO MEDICAL RECORDS: I hereby acknowledge that I have
reviewed/received the medical records from the University of Colorado Hospital on the above named patient.
Date
Signature
Date
Witness Signature
MRD12546 M/Q (Rev 01/11) DOD
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Parent category: Legal