Medical Records Request Call (303) 772-3300 to schedule an appointment. Back to Patient Info 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 PhoneDate of Birth Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code For the purpose of Connuing care/treatment Legal Personal Use Insurance Other Please ExplainPlease Explain I hereby authorize my release of protected health information as described below, to: SELF Name of Individual/Organization Please list Name of Individual/OrganizationPlease list Name of Individual/Organization Address Street Address AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneFaxRequested 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 AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Delivery Method Mail Pick Up from Eye Care Center Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email NOTE: Unencrypted email is not protected from unauthorized access by unknown third parties once it leaves Eye Care Center of Northern Colorado electronic systems, and may be subject to unauthorized use or disclosure. All emails will be sent encrypted unless you specifically request they not be by checking this box:* Fax NumberPhoneType of Access Requested Complete Chart Imaging/Testing (Cannot fax Color Photos) Billing/Itemized Records Other Please ExplainPlease Explain For the time periodStart Date Month Day Year End DateEnd Date Month Day Year THIS REQUEST CAN TAKE UP TO 21 BUSINESS DAYS TO COMPLETE I am a pysician and need records ASAP Records needed ASAP. Patient has an appointment on: Month Day Year 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* MM slash DD slash YYYY 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.
