Online medical records request

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Request for pick-up of medical record copies

You may also request a printed copy of your medical records. However, 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:

Memorial Hospital: change of location for medical records: Medical Records at Memorial Hospital Central has moved to the MAC building (Memorial Administrative Center). Patients can request medical records in person by visiting offices at either the MAC (2420 E. Pikes Peak Avenue, 80909) or at Memorial Hospital North (4050 Briargate Parkway, 80920). Office hours are 8:00 a.m. – 4:30 p.m.
Questions? Call 719.365.5277

Online request form

Request for medical records

Request for Medical Records

  • Request for Medical Records

    PICK-UP ONLY
    Authorization to Disclose Protected Health Information

  • Must be at least 10 business days from today. Please note the HIM department is not open Saturday or Sunday.
    If different than above, a signed authorization must be completed for HIPAA compliancy.
  • The Health Information Department will not email or fax medical records.

  • Note: Please provide specific dates of service. Dates of service listed as "Any/All" will not be processed.
    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.
  • or 180 days from the date signed below and covers only treatment for the dates specified above.
    NOTE: Fees/charges will comply with all laws and regulations applicable to the release of information.
    • No charge for pages 1-10
    • .50 cents for each page from 11-40
    • .33 cents for each additional page

    Additionally, an initial set of radiological films/CD-ROM can be provided at no cost to a patient for physician or facility referral. (A signed authorization is required for HIPAA compliancy).

    However, a fee of $5.00 per sheet of film and $7.00 per CD-ROM will be charged for additional copies.

    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.
  • This field is for validation purposes and should be left unchanged.

Questions about medical records?

  • Medical Center of the Rockies / Poudre Valley Hospital: 970.624.1350
  • Memorial Hospital: 719.365.5277
  • University of Colorado Hospital: 720.848.1031
  • Yampa Valley Medical Center: 970.871.2387

Reviewing your medical record or that of your child

You may review your or your child’s protected health information in the health information management department at UCHealth during business hours.