Online medical records request

Request medical record copies

UCHealth is required by law to obtain your written permission before releasing any copies. If you desire to receive a copy of your medical records:

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Patient/guardian requester

Complete the online form “Request for Medical Records” below.

Non-patient/guardian requester

Email, fax, or mail a written and signed request to the UCHealth Health Information Management department.

- Authorization to Disclose Health Information – English (PDF)
- Authorization to Disclose Health Information – Español (PDF)

Request for Medical Records

Authorization to Disclose Protected Health Information

Request to have your medical records be delivered through the mail, email, fax, or you can pick them up at the medical facility.
Patient's Name*
First Last
Birth Date*
MM slash DD slash YYYY
Phone*
Please call when ready?
- Yes
Best Time to Reach Me
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Email
Medical record delivery preference type*
Fax Number*
Choose Your Pick-Up Location*
Please upload photo ID
Drop files here or

Max. file size: 250 MB.
Requested Pickup Date - A valid photo ID and any fees assessed are due at time of pick-up.
MM slash DD slash YYYY

Must be at least 10 business days from today. Please note the HIM department is not open Saturday or Sunday.
I authorize release to:
- Same as Above
If different than above, please email, fax or mail a written and signed request to ROI department.
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Note: Please provide specific dates of service. Dates of service listed as "Any/All" will not be processed.
Treatment dates and description of information to be released (0 characters - Max 250)
Purpose for Request (0 characters - Max 250)
Where were you treated?*
I agree to do a request electronically.
- Yes
I hereby consent to disclose information that may contain alcohol, drug abuse, psychiatric, HIV testing, HIV results, AIDS information, or any communicable disease.
- Yes
- No
Yes, I understand the following:
- Yes
See the paragraph below:
- If the organization authorized to receive the information is not a health plan or health care provider, the released information may no longer be protected by federal privacy regulations.
- Multiple requests are authorized if the purpose of the request remains the same.
- I have a right to revoke this authorization at any time and if I revoke this authorization, I must do so in writing and present the written revocation to the department that I have authorized to release the information.
- Any revocation will not apply to information that has already been released in response to this authorization.
- I need not sign this form to ensure health care treatment.
I request this authorization to expire on:
MM slash DD slash YYYY

or 180 days from the date signed below and covers only treatment for the dates specified above.
Yes, I am also aware of fees, allowable state and federal rate, that may apply.*
- Yes
Additionally, an initial set of radiological images can be provided at no cost to patient for physician or facility referral.

However, a fee of $6.50 per request may be charged for additional copies.
I agree.*
- Yes
Important Warning: The documents accompanying this message are intended for the use of the person or entity to which this message is addressed. These documents may contain information that is privileged and confidential, the disclosure of which is governed by applicable law. Unauthorized re-disclosure or failure to maintain confidentiality could subject you to penalties described in Federal and State law. If you are the employee or agent responsible to deliver this information to the intended recipient, you are hereby notified that any dissemination, distribution or copying of this information is STRICTLY PROHIBITED.
Name
This field is for validation purposes and should be left unchanged.

UCHealth Health Information Management

Northern Colorado

UCHealth Medical Center of the Rockies
Attention: Medical Records
2500 Rocky Mountain Avenue
Loveland, CO 80538

Fax: 970.624.1392
Email: ROI@uchealth.org

Metro Denver

UCHealth University of Colorado Hospital
Attention: Medical Records
12605 E. 16th Avenue
Mailstop A025
Aurora, CO 80045

Fax: 720.848.5551
Email: ROI@uchealth.org

Southern Colorado

Memorial Administrative Center
Attention: Medical Records
2420 E. Pikes Peak Avenue
Colorado Springs, CO 80909

Fax: 719.365.6974
Email: ROI@uchealth.org

Questions about medical records?

Greeley Hospital: 970.652.2300
Highlands Ranch Hospital: 720.516.0015
Longs Peak Hospital: 720.718.1560
Medical Center of the Rockies / Poudre Valley Hospital: 970.624.1350
Memorial Hospital: 719.365.5277
Pikes Peak Regional Hospital: 719.374.6076
University of Colorado Hospital: 720.848.1031
Yampa Valley Medical Center: 970.871.2387

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Request medical records

Online medical records request

Request medical record copies

Request for Medical Records

UCHealth Health Information Management

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Online medical records request

Request medical record copies

Request for Medical Records

UCHealth Health Information Management

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