Medical Records Request

This form is to be used by Physicians or Healthcare Facilities only. If this is a stat request, please call 303.398.1256. After you submit the form below, it will take one to three business days for the record to be faxed or mailed to contact information you provided. If you have questions or would like to speak with someone, you can contact Health Information Management by phone at 303.398.1256 from 8 a.m. to 4 p.m. Mountain Time Monday through Friday.

This form is to be used by Physicians or Healthcare Facilities only. 

Provider Information

Provider First name

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Provider Last name

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Title

Name of requesting office or facility

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National Provider Identifier (NPI)

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Provider Country

United States Abkhazia Afghanistan Aland Albania Algeria American Samoa Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Aruba Ascension Ashmore and Cartier Islands Australia Australian Antarctic Territory Austria Azerbaijan Bahamas, The Bahrain Baker Island Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Antarctic Territory British Indian Ocean Territory British Sovereign Base Areas British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China, People's Republic of China, Republic of (Taiwan) Christmas Island Clipperton Island Cocos (Keeling) Islands Colombia Comoros Congo, (Congo – Brazzaville) Congo, (Congo – Kinshasa) Cook Islands Coral Sea Islands Costa Rica Cote d'Ivoire (Ivory Coast) Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Islas Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern and Antarctic Lands Gabon Gambia, The Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong Howland Island Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jarvis Island Jersey Johnston Atoll Jordan Kazakhstan Kenya Kingman Reef Kiribati Korea, North Korea, South Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Midway Islands Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar (Burma) Nagorno-Karabakh Namibia Nauru Navassa Island Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Cyprus Northern Mariana Islands Norway Oman Pakistan Palau Palmyra Atoll Panama Papua New Guinea Paraguay Peru Peter I Island Philippines Pitcairn Islands Poland Portugal Pridnestrovie (Transnistria) Puerto Rico Qatar Queen Maud Land Reunion Romania Ross Dependency Russia Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia Somaliland South Africa South Georgia & South Sandwich Islands South Ossetia Spain Sri Lanka Sudan Suriname Svalbard Swaziland Sweden Switzerland Syria Tajikistan Tanzania Thailand Timor-Leste (East Timor) Togo Tokelau Tonga Trinidad and Tobago Tristan da Cunha Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu U.S. Virgin Islands Uganda Ukraine United Arab Emirates United Kingdom Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Wake Island Wallis and Futuna Yemen Zambia Zimbabwe

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Provider International Phone number

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Provider International address

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Provider Email

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Patient Information

Patient First name

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Patient Last name

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Patient Date of Birth

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Needed for continuation of care

Service from

 

Service to

 

Information requested

Clinic Summary/consultation
Procedure
Laboratory
Radiology
Pulmonary test
Cardiology test
Other

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Please send the requested information by

Email
Fax

By checking this box I certify that I am an authorized healthcare provider and I understand that my signature is required to validate this authorization. I understand that falsifaction of identity on this form constitutes as fraud.

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