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

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Patient Information
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