Medical Records Request

ECCNC takes the privacy and security of your personal information very seriously. All data submitted through the form on this page is transmitted and stored using HIPAA compliant encryption technology. If you don’t feel comfortable providing information in a specific box then please write the following in the box: “Please ask”.

** PLEASE NOTE: IF THIS FORM IS NOT COMPLETED IN FULL, IT WILL DELAY THE TIMING OF THIS REQUEST **

Patient Name*

First Last

Email

Primary Contact Phone

Date of Birth*

Address

Street Address Address Line 2 City State ZIP Code

For the purpose of

Continuing care/treatment
Legal
Personal Use
Insurance
Other

Please Explain

I hereby authorize my release of protected health information as described below, to:

SELF
Name of Individual/Organization

Please list Name of Individual/Organization

Address

Street Address State ZIP Code

Phone

Fax

Requested Format & Delivery Method

Paper (Charges Apply)
USB ($5.00 Charge for USB)
Encrypted Email (No Charge)
Fax (No Charge)

Delivery Method

Mail
Pick Up from Eye Care Center

Address

Street Address Address Line 2 City State ZIP Code

Delivery Method

Mail
Pick Up from Eye Care Center

Address

Street Address Address Line 2 City State ZIP Code

Email

Fax Number

Phone

Type of Access Requested

Complete Chart
Imaging/Testing (Cannot fax Color Photos)
Billing/Itemized Records
Other

Please Explain

For the time period

Start Date

End Date

THIS REQUEST CAN TAKE UP TO 21 BUSINESS DAYS TO COMPLETE

I am a physician and need records ASAP

Records needed ASAP. Patient has an appointment on:

I acknowledge, and hereby consent to such, that the released information may contain alcohol, drug abuse, psychiatric, HIV results, or AIDS information. I understand that this authorization may be revoked by me at any time except to the extent that action has already been taken in reliance upon it. The information or disclosed pursuant to the authorization may be subject to re-disclosure by the recipient and no longer protected. I understand that there may be a fee involved with the fulfillment of this request (See the fee schedule below). I understand that the term “complete chart” for release of protected health information means that only records generated by this facility will be released. I have read the above and authorize the disclosure of the protected health information.

Date*

Per State of Colorado (CO) Medical Record Fee Schedule House Bill 14-1186: First 10 pages or fewer will incur a flat fee of $18.53; Pages 11-40 will incur a fee of $0.85 per page; Pages 41+ will incur a fee of $0.57 per page. Postage fee will include actual cost of mailing.

THIS REQUEST CAN TAKE UP TO 21 BUSINESS DAYS TO COMPLETE

QUICK LINKS

SERVICES

RESOURCES

LOCATIONS

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