Request Medical Records Online

Online medical records request

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:

Step 1: Complete the Request for Medical Records form (below) to make your pick-up request. If someone other than the patient will be picking up records proceed to step 2.
Step 2: Print, complete and bring with you the “Authorization to Disclose Protected Health Information form” to one of our locations.
- Authorization to Disclose Health Information – English (PDF)
- Authorization to Disclose Health Information – Spanish (PDF)

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Online request form

Request for medical records

Request for Medical Records

Request for Medical Records
Authorization to Disclose Protected Health Information
Patient's Name*
First Last
Birth Date*
Date Format: 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 or a scan of a valid photo ID
Drop files here or
Requested Pickup Date - A valid photo ID and any fees assessed are due at time of pick-up.
Date Format: 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, a signed authorization must be completed for HIPAA compliancy.
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:
Date Format: 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, outlined below, for copy services that may apply.*
- Yes
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 $6.50 per sheet of film and $6.50 per CD-ROM will 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.

Questions about medical records?

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: 719.687.5720
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.

Request medical records

Online medical records request

Request for pick-up of medical record copies

Online request form

Request for Medical Records

Request for Medical Records

Questions about medical records?

Reviewing your medical record or that of your child

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Online medical records request

Request for pick-up of medical record copies

Online request form

Request for Medical Records

Request for Medical Records

Questions about medical records?

Reviewing your medical record or that of your child

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