Medical Record Release 2022

Patients Please Use a Separate Form For Each
Medical Provider Medical Records Request.

Patient Name*

First NameLast Name

Date of Birth*

MM/DD/YYYY

Phone Number*

Area CodePhone Number

Email Address*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Name of Person or Organization to Release Your Medical Records From:*

Person or Organization Fax Number: *

Medical Record (s) are to be released to:
Donna Grandi DNP,PMHNP-BC,FNP-BC
Electronic FAX ONLY (303) 848-4842 (Please No Hard Mail Copies)

Reasons for Request
Continuity of Care

Patient Consent For Medical Records To Be Released

Requested Information to be Released

I understand and agree to the following four statements per my signature and date below:

I understand and agree that this authorization will expire one year from the date below or on date below.
I understand and agree that I may revoke this authorization at any time by notifying the releasing organization in writing, but my revocation will not affect any releases made or other actions taken before the date of my revocation.
I understand and agree that for use other than referral to a specialist, there may be a fee for services. Third party Life, Accident and Legal Firms requesting patient medical records are required to pre- pay a $75 fee for ancillary and transfer services. After receipt of payment, all medical records will be immediately faxed to said party.
I understand and agree that incomplete information on this form may delay the process of this request.

I understand and agree to the 4 statements above per my signature and date below:*

YesNo

Date*

MM/DD/YYYY

Electronic Signature of patient or patient’s legal representative*

Clear

Name of patient or patient’s legal representative

First NameLast Name