Medical Records Request "*" indicates required fields 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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Are you requesting records from or sending records to an individual/organization?* Requesting Records From Sending Records To Records Requested FromPlease list Name of Individual/Organization*Please list Name of Individual/OrganizationAddress* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*FaxEmail Send Records ToPlease list Name of Individual/Organization*Please list Name of Individual/OrganizationAddress* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*FaxEmail Requested Format / Delivery MethodType of Access Requested* Complete Chart Imaging/Testing (Cannot fax Color Photos) Billing/Itemized Records Other What type of access are you requesting?*Requested Format & Delivery Method* Paper (Charges Apply) USB ($5.00 Charge for USB) Encrypted Email (No Charge) Fax (No Charge) Will you pick up from the office or do you need it mailed?* Pick-up from office Send in mail to address Paper / Mailing Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Fax Number*Email* 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. Δ
