Providers Requesting Patient Records

This form is to be used by Physicians or Healthcare Facilities only. If this is a stat request, please call 303.398.1256. After you submit the form below, it will take one to three business days for the record to be faxed or mailed to contact information you provided. If you have questions or would like to speak with someone, you can contact Health Information Management by phone at 303.398.1256 from 8 a.m. to 4 p.m. Mountain Time Monday through Friday.
This form is to be used by Physicians or Healthcare Facilities only. 
Provider Information

Provider First name *
Provider Last name *
Name of requesting office or facility *
National Provider Identifier (NPI)
Provider Country * 
Provider International Phone number *
Provider International address *
Provider Email * 
Patient Information
Patient First name *
Patient Last name *
Patient Date of Birth *  
Needed for continuation of care
Service from   
Service to   
Information requested

Please send the requested information by

By checking this box I certify that I am an authorized healthcare provider and I understand that my signature is required to validate this authorization. I understand that falsifaction of identity on this form constitutes as fraud. * 

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